Orthodontic Practice US - January/February 2015 - Vol6.1

clinical articles • management advice • practice profiles • technology reviews January/February 2015 – Vol 6 No 1

PROMOTING EXCELLENCE IN ORTHODONTICS The fundamental objectives of early interceptive treatment Dr. Bradford Edgren

Corporate spotlight GC Orthodontics

Practice profile

Dr. Michael S. Stosich

BioDigital Orthodontics part 13

Drs. Rohit C.L. Sachdeva Takao Kubota and John Lohse

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A dual-arch protocol with accelerated movement and less discomfort Drs. George Schudy and Larry White

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EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

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New Year’s resolution — think outside the treatment box

A

lbert Einstein stated, “If you can’t explain it simply, you don’t understand it well enough.”

If you find that the results of your treatment are not up to your expectations, review your diagnostic techniques and treatment plans. You can’t treat what you don’t diagnose, and you can’t diagnose what you don’t know. In this new year, think about your orthodontic treatment of your patients as being designed around the treatment of the total face, rather than the narrower objective of treating just the teeth and/or the occlusion. Consider the future growth of your patients. Think about how your treatment results will be reflected in the patient 10 years, 20 years, or 40 years from the conclusion of your orthodontic care. Will you be proud of those results when you see your patients home on vacation? Think about how your young patients continue to grow, develop, and mature years after they have left your care. Did you provide them with a proper and functional occlusion, take into consideration upper airway obstructions, or provide for future dentofacial growth? Dentofacial growth occurs over years, not months. It is not constrained by treatment plans that expect teeth to be in specific positions by the next appointment period.

Growth can be unpredictable; it’s what makes orthodontic treatment of the young patient difficult, challenging, and yet rewarding. It is not always easy to take the more difficult “path less traveled,” but if it benefits the patient in the long run, then it was the path best taken.

Appropriate early interceptive treatment can produce life-changing results for young, developing orthodontic patients. Einstein said, “Education is not the learning of the facts, but the training of the mind to think.” With the furthering development of 3D imaging, diagnosis, and treatment planning, think about your patients in all four dimensions, including the fourth dimension, growth. A case that appears to be treated to proper balance at age 12 could be a failed result by age 18 or 21 after future excessive dentofacial growth has fully expressed itself.

Technology is imperative in any profession but should never be substituted for a proper and thorough diagnosis. Furthermore, technology is not a substitution for proper and established treatment techniques or a crutch for mid-treatment corrections. Continually think about the direction you want your treatment to follow for your maturing patients. Will that limited 12- or 18-month treatment plan fully benefit the patient? Will your treatment plan take growth into account? Moreover, review your extraction prerequisites and protocols. In the early mixed dentition, deciduous teeth are natural space maintainers. Early removal of deciduous teeth generally results in the loss of arch length and potentially delays the eruption of succedaneous teeth. All patients require different treatment plans and treatment implementations. A routine or “cookbook” approach to treatment and treatment planning can lead to routine failure.

Finally, critically evaluate the scientific articles you read and the lectures you attend.

Thoroughly read your scientific articles; you will find that the some of the most important information is in the details and not always included in the abstract’s conclusion.

This new year, let us become “orthodontists of value” by making a positive difference in our patients’ lives.

Bradford Edgren, DDS, MS Private practice at Orthodontic Associates of Greeley (Colorado) Diplomate, American Board of Orthodontics Member of the Southwest Component of the Edward H. Angle Society

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Volume 6 Number 1

Bradford Edgren, DDS, MS, earned both his Doctorate of Dental Surgery, as Valedictorian, and his Master of Science in Orthodontics from the University of Iowa, College of Dentistry. He is a Diplomate, American Board of Orthodontics, and a member of the Southwest Component of the Edward H. Angle Society. Dr. Edgren has presented nationally and internationally to numerous orthodontic groups on the importance of orthodontic diagnosis, early interceptive orthodontic treatment, CBCT, and upper airway obstruction. He has been published in AJO-DO, the American Journal of Dentistry, as well as other orthodontic publications. Dr. Edgren currently has a private practice in Greeley, Colorado.

Orthodontic practice 1

INTRODUCTION

January/February 2015 - Volume 6 Number 1

TABLE OF CONTENTS

Practice profile

Michael S. Stosich, DMD, MS, MS

6

Engineering the future of orthodontics

Orthodontic concepts BioDigital Orthodontics Management of patients with open bite (2): part 13

Drs. Rohit C.L. Sachdeva, Takao Kubota, and John Lohse discuss the non-surgical correction of open bites in Class 3 and Class 2 patients .......................................................13

Propelling orthodontics Topical anesthesia and patient messaging

.......................................................24

Corporate spotlight GC Orthodontics

10

Global experts in orthodontics

ON THE COVER Cover photo courtesy of Dr. Adam Schulhof Article begins on page 42.

2 Orthodontic practice

Volume 6 Number 1

A Two Day Exploration of All Things Ortho in Gorgeous San Diego, California!

Where: Loews Coronado Bay Resort, San Diego, CA

When: Feb. 18 - 21, 2015

The DENTSPLY GAC Orthodontic World Congress is dedicated to bringing top quality professional and clinical development to further the advancement and discussion within the orthodontic community.

This year’s meeting will feature sessions on a range of topics from Contagious Marketing to the latest techniques in Clinical Orthodontics. The conference will include notable speakers, workshops tailored for orthodontists and staff, group discussions, and a half-day tactical session on implementation of practice differentiators for your staff.

The 2015 Annual Meeting brings together orthodontists from around the world for two days of meetings, insightful speakers, recreation and plenty of networking time that we are sure will create a community of valuable relationships.

Keynote Speakers: Jonah Berger Steve Curtin Jon Acuff

Featuring: Thursday 2/19 Dr. Ben Burris Dr. Lou Shuman

We look forward to seeing you in California!

Visit www.mygcare.com/owc2015

Featuring: Friday 2/20 Dr. Antonino Secchi Dr. Ryan Tamburrino Dr. Martin Palomo

Dr. Julia Garcia-Baeza Dr. Rebecca Bockow Dr. Raffaele Spena

TABLE OF CONTENTS

Continuing education A dual-arch protocol with accelerated movement and less discomfort Drs. George Schudy and Larry White discuss a way patients can have less pain with their gain...........................34

Orthodontist’s viewpoint

Treating sleep disorders with oral appliances Dr. Ronald Perkins discusses symptoms of sleep disorders and his treatment protocol...........................38

Technology

On the fence about new technology? It might be time to dive in Dr. Adam Schulhof discusses the 3M™ True Definition Scanner for digital impressions.....................................42

Clinical research

Sleep apnea treatment: a survey investigating current orthodontic treatments and philosophies A study by Drs. Ryan Walter, Donald Rinchuse, and Daniel Rinchuse shows a wide range of responses on the treatment of OSA............................ 44

4 Orthodontic practice

Continuing education

26

The fundamental objectives of early interceptive treatment

Dr. Bradford Edgren discusses normalizing the dentofacial skeleton at an early age

Product profile

Ortho Classic’s H4™ System has a growing suite of orthodontic solutions .......................................................50

Practice development

Does your practice have an open door for curious patients?

Advice on spreading the word on your practice’s treatment options ........................................................52

Practice development

The four imperatives of review syndication Diana Friedman discusses the value of online reviews to the dental practice ........................................................53

Industry news/ Materials & equipment.........................56

Volume 6 Number 1

PRACTICE PROFILE

Michael S. Stosich, DMD, MS, MS Engineering the future of orthodontics What can you tell us about your background?

First, I realized that I thrive on the study of biomechanics. From college to graduate school, I delved into the study of bioengineering and biomechanics because it offered a unique opportunity to express my fascination with the physics of movements. I also discovered there is much to be learned in the field of bioengineering as it relates to the study of dentistry.

Thereafter, I launched my research to study methods regarding how dental implants can better integrate using stem cell sources. It helped me gain an understanding into how mechanical stress can contribute to tissue integration. In addition, I also pursued research in soft-tissue engineering.

Using one’s own stem cells, we set out to discover ways to regenerate a defective tissue part. The motivation for this research was in part from its wide-ranging and critical implications to current clinical practices, including that of orthodontics. From my courses in graduate study at University of Illinois and Columbia University, I was well aware of the many challenges facing clinicians who are treating patients with facial deformities. The findings from this project drew excitement among reconstructive clinicians, and it was very rewarding to witness my research being the foundation for further investigations. I continued to pursue this question specifically to craniofacial applications at The Children’s Hospital of Philadelphia.

Why did you decide to focus on orthodontics?

I am drawn to orthodontics because of its ability to make life-changing and lifelong differences. While the cosmetic changes are most visible, treatment truly translates to multiple facets: function, self-confidence, and overall harmony of one’s appearance.

Orthodontics is a rarity among the specialties in this regard, and my conviction in this pursuit inspires me to continue the betterment of the specialty.

How long have you been practicing, 6 Orthodontic practice

Dr. Stosich and one of his patients who benefited from his smile foundation

and what systems do you use?

Dr. Michael Duda, a restorative dentist, and Dr. Stosich collaborating on a case utilizing

I’ve been in private 3D planning practice since 2011. I utilize image-guided orthodontics and 3D treatment planning to simulate optimal treatment outcomes.

What training have you undertaken?

I have a passion for lifelong learning.

I have undertaken extensive training in 3D image-guided orthodontics, suresmile®, Lingual Orthodontics, and Invisalign®. My area of expertise is in robotically assisted orthodontics. My training has provided me with the foundation for treating the gamut of patients — from the routine to the most complex. Additionally, a strong tenet of all my background training, especially learned in the research setting, is the importance of collaborative teamwork. I have always worked on collaborative teams, and that’s exactly what I continue to do.

Who has inspired you?

I have been inspired by many outstanding professionals throughout my training. In research, Dr. Hyun-Duck Nah is a first-rate

scientist who taught me much. Clinically, I’m inspired most by Dr. Rohit Sachdeva, whom I sincerely believe is the orthodontist of our time, and who has done much for orthodontics.

What is the most satisfying aspect of your practice?

I am most rewarded and gratified by the changes I see in my patients’ faces and ultimately in the quality of their lives. I support my patients’ dreams in any way I can through scholarships and pay-it-forward models.

Professionally, what are you most proud of?

I’m proud to be the orthodontic director of the Craniofacial Anomalies and Cleft Lip/Palate Team at the prestigious University of Chicago Medicine and Comer Children’s Hospital. It’s extremely rewarding to be working with some of the most difficult cases in orthodontics and craniofacial deformities. The changes in these children through the interdisciplinary approach Volume 6 Number 1

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3Shape Orthodontics™ 3D scanning, archiving, treatment planning & analysis, patient management, communication tools, and CAD appliance design.

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PRACTICE PROFILE

Dr. Stosich and his newborn baby, Alexander

Dr. Stosich pictured here with Hadley School for the Blind President Charles Young and the Women’s Board President. Dr. Stosich is a trustee of the largest international institution of the blind, which serves patients in nearly every country around the world

Dr. Christine Lee, a pediatric dentist, doing a virtual consult with Dr. Stosich on a mutual patient

and treatment we yield are phenomenal. I also am involved in the University’s craniofacial research lab where I continue my studies The iDentity Orthodontics team in bone biology and orthodontic/craniofacial research. university, my time is stretched thin. But I’m also very proud of the amount of it’s always such a joy to come home to my charitable work I have been involved in. new baby and wife, who have been such an It’s a central tenet in my practice that we amazing source of comfort and inspiration. must pay it forward to help those without the means to seek orthodontic care through What would you have become if our charitable programs, including Smiles for you had not become a dentist?

Service, Smiles Change Lives®, and Fresh I would have stayed a biomedical engineer. It was rewarding and stimulating. But Start Caring for Kids Foundation.

I’m so glad I became an orthodontist; I need What do you think is unique about the patient interaction.

your practice?

We strive to be a patient-centered practice in every sense of the word. I spend extensive time on each patient’s care plan with 3D treatment simulations and analytic study, which results in more efficient therapeutics and an easier time in braces. We treat not just the malocclusion, but the whole person. Being a positive influence and a fun, safe place for the child (or adult) to visit is vital. I also believe in always being available for the general dentists who have entrusted me with their patients. Driving an orthodontic treatment plan in concert with their periodontal and restorative goals is integral in providing optimal and continuous patient care.

What has been your biggest challenge?

My biggest challenge is balancing work and family. With two practices and the 8 Orthodontic practice

What is the future of orthodontics and dentistry?

I feel the future of orthodontics will be increased collaboration with both patients and dentists. Patients today are more educated than ever before, and having them play a role in the care cycle can yield more fruitful treatment outcomes. Technology, of course, continues to evolve, but we must never be overtaken by treatment systems or the latest gadget without doing due diligence supported by science.

What are your top tips for maintaining a successful practice?

Maintaining a successful practice is hard work, one that requires constant nurturing.

The single most important thing I do is treating my patients like family. Looking out for their best interests is fundamental. With all the financial pressures these days, you can

Dr. Stosich teaching the latest techniques at the University of Dijon Children’s Hospital

Top Ten Favorites 1. Orthodontics 2. My incredible iDentity Orthodontics team 3. The talented dentists I collaborate with 4. 3D imaging — i-CAT™, Imaging Sciences International 5. Good coffee and better wine 6. Learning — I believe we must always be students at heart to improve 7. Research — it’s been a part of me for so many years 8. Brunch and dinner at nice restaurants 9. Meeting new, interesting people daily 10. Last, but not least, my family

never, ever go wrong by doing what’s right for your patient family.

What advice would you give to budding orthodontists?

Orthodontics is a wonderful field, and I truly believe I have the best job in the world.

The dynamic continues to change, with increased competition and self-proclaimed miracle systems flooding the market. I’d say, stay the course, stick to an evidenced-based practice, and be patient. Good things come to those that work hard and for the right reasons.

What are your hobbies, and what do you do in your spare time?

I enjoy running with my Old English Bulldog, rock climbing, and traveling with my family. OP Volume 6 Number 1

Pre-treatment airway volume

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Post-treatment airway volume

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CORPORATE SPOTLIGHT

G

C Orthodontics is a full-service provider of premier products and services from self-ligating metal and ceramic brackets, to traditional twins, lingual, esthetics, bands, buccal tubes, wires, and many other tooth movement-related supplies. As a subsidiary of GC Corporation, a worldleading manufacturer of dental products and innovators of Fuji™ branded glass ionomer technology, GC Orthodontics rests upon 93 years of heritage. We are also the co-distributor of Tomy® Inc., a world-class manufacturer of orthodontic appliances for the past 50 years. GC Orthodontics is further led by a global team of associates with most of their professional lives invested in the orthodontic field. With a history of innovation behind us, precision manufacturing supplying us, and market expertise leading us, we look forward to enhancing the specialty of orthodontics, your practice, and the health of your patients as we grow into the future.

Experience metal bracket

A new spirit After the Tsunami disaster of 2011 in Fukushima Japan, two companies were faced with different, yet similar questions regarding their future and their legacies. GC Corporation, manufacturer of high-quality dental materials for over 90 years, felt even more driven to contribute positively toward society and its oral health by expanding into the specialty of Orthodontics. While at the same time, Tomy® Inc., precision manufacturer of orthodontic appliances for over 45 years, was compelled to prove its resilience as a people and rebuild its proud competence of producing the world’s best orthodontic products as a business.

Together, they then met and agreed to terms that would bring them closer to achieving their goals. Soon after, GC Corporation would proceed to assemble a team of associates whose expertise in the orthodontic market would serve to effectively lead their new direct distribution business — GC Orthodontics.

Culture and community GC Orthodontics will be delivering this new spirit as part of our culture into the orthodontic community. As we plan to further develop our business into the future, we 10 Orthodontic practice

Legend medium bracket

equally look to develop our relationships with you as well. Our management team has over 100 combined years of orthodontic experience and has had the privilege of collaborating directly with many of the world’s leading clinicians of the past. Moving forward, we would like to collaborate with each one of you so that the innovations we develop are ensured to meet your needs, and the needs of your patients, within the special community we share.

Brackets, bands, and wires The orthodontic market has realized many changes in the form of techniques and technologies in just the past few years.

Legend mini bracket

Although plastic tray aligners and technological-based solutions are viable adjuncts within your practice, the primary modality for orthodontic treatment of moderate to severe malocclusions still remains brackets, bands, and wires. We at GC Orthodontics strongly believe that years of clinicianenhanced designs combined with precision manufacturing and quality control do make a difference in which appliances you should choose. Whether they are features as seemingly simple as smooth rounded ball hooks, chamfered slots, swept tie-wings, and anatomically shaped bases, or as integral as steel hardness, heat treatment, and laserwelding processes, you can trust that they Volume 6 Number 1

YOU HAVE A CHOICE GC Orthodontics has two aesthetic bracket systems to choose from – Experience or Chic.

Both afford you confidence where you need it most: in your mechanics, in your de-bonding procedure, and in your providing the most attractive, comfortable, and efficient appliance option to your patients. Whether you prefer self-ligation or a traditional twin, strength, efficiency, and effectiveness are now available in either form.

• High translucency for optimal aesthetics.

• Superior strength for full treatment planning.

• A mechanical base for reliable bonding/de-bonding.

• Smooth facial contours for maximum patient comfort.

• Uniform slot surfaces for reduced friction.

Learn more about our Experience and Chic Ceramic Bracket Systems by calling 888-332-4883 or visiting us at www.GCOrthodontics.com

CORPORATE SPOTLIGHT are all combined toward providing you with the highest level of quality and efficiency in every brand GC Orthodontics provides.

Experience The Experience brand is our premier collection of self-ligating appliances, all offering their own unique form of precision, esthetics, and patient comfort without compromise to your orthodontic technique or treatment plan. Available in metal, ceramic, and two versions of low-profile linguals, there is an efficient self-ligating option for almost any indication.

Legend Our Legend line is a timeless combination of traditional twin design. Manufactured with a level of precision that sets it apart from other twin metal appliances, Legend is available in both standard and mini sizes.

Chic Sharing many of the same features and manufacturing processes as our Experience Ceramic SL bracket, but in the configuration of a traditional twin, Chic is one of the most innovative and effective ceramic brackets on the market today. Injection molding affords uniformity, strength, and a true mechanical base, while its level of translucency complements the patient’s tooth shade and makes for a highly esthetic solution.

Bands GC Orthodontics offers two styles of bands that differ in their temper and formability, but not in their quality or performance.

Sure-Snap bands are a more traditional, rigid band that seats with a Snap. A-Fit bands have a slightly higher crown height and are more formable to the anatomy of each individual tooth.

NiTi wires Not all NiTi wires are the same — methods and duration of heat treatment can result in a variety of forces at variable temperatures and determine whether the wire is truly Superelastic or not. A set force, at a particular transformation point, that is being consistently deflected over an extended period of time is what you want, and that is what you get with GC Orthodontic’s Initialloy, Bio-Edge, and Bio-Active archwires — Body heat activated, truly Superelastic wires that deflect a predictable amount of force over an extended period of time.

12 Orthodontic practice

Supply Chain – Value Chain Your practice is your business, and every aspect of that business leading to the point when service is delivered represents your Value Chain. Your business process, staff members, supportive systems, even your treatment delivery all make up the value that your patient receives. Believe it or not, your Supply Chain is an integral link within this chain as well. Whom you partner with, how you work with them, and how they deliver that value are a significant part of your business. The quality of the materials you use, the availability of those materials, the amount that you need to purchase and carry in order to qualify for a discount, and the people who represent them are all an important part of making the decision on who should serve as a supplier to your business. Differences between one or another can ultimately cost you more than any promotion or program that may seem appealing at the time. We at GC Orthodontics are confident in how we can contribute positively towards your practice — With quality products you can

rely on, quality people you can relate to, and a global network of service centers between GC Orthodontics America and GC Orthodontics Europe that provide all the integral linkage you need for both your Supply and Value Chain.

Vision for the future Our vision for the future at GC Orthodontics is to develop a business that makes a positive contribution to the specialty by improving the effectiveness of orthodontic treatment and the overall oral health and esteem of its patients. We intend on delivering meaningful products and services to your practice through a culture of collective associates whose expertise and focused commitment is consistent with your needs and values. We certainly hope, therefore, that you consider GC Orthodontics in the future, and we welcome the opportunity to serve and partner with you as we grow moving forward. OP This information was provided by GC Orthodontics.

Volume 6 Number 1

Drs. Rohit C.L. Sachdeva, Takao Kubota, and John Lohse discuss the non-surgical correction of open bites in Class 3 and Class 2 patients Introduction The successful management of a patient with an open bite requires both the selection of an appropriate treatment occlusal plane and controlling its level and cant.1 In this paper, the non-surgical correction of open bites in patients with two distinct skeletal patterns, namely, a skeletal Class 3 and Class 2, is described.2-4

Patient BG Patient BG, a 20-year-old male patient presented with a Class 3 skeletal pattern with a long facial height. The patient also demonstrated an open bite, a slightly constricted maxillary buccal segment, and a functional mandibular shift to the patient’s left (Figures 1 and 2). A Virtual Diagnostic Simulation (VDS) plan was designed in two steps. The first

step simulated the asymmetric mandibular shift correction. The second step considered the correction of the occlusal plane, the archwidth, and the detailing of the occlusion.

The maxillary functional occlusal plane was chosen as the treatment plane of occlusion. The upper esthetic occlusal plane was extruded to the level of this plane (Figure 3).

Archform and archwidth were coordinated with minimal dental movement (Figure 3E). The lower anterior occlusal plane was extruded to the level of the maxillary functional occlusal plane (Figure 4).

Treatment began by fully bonding the patient with 0.18" 3M Unitek™ brackets, and .016" CuNiTi AF 35ºC upper and lower initial alignment archwires were engaged.

A Therapeutic scan was taken 10 weeks later (Figure 5). The virtual target setup was

Rohit C.L. Sachdeva, BDS, M Dent Sc, is the co-founder and Chief Clinical Officer at OraMetrix, Inc. He received his dental degree from the University of Nairobi, Kenya, in 1978. He earned his Certificate in Orthodontics and Masters in Dental Science at the University of Connecticut in 1983. Dr. Sachdeva is a Diplomate of the American Board of Orthodontics and is an active member of the American Association of Orthodontics. He is a Clinical Professor at the University of Connecticut and Temple University, and the Hokkaido Health Sciences Center Japan. In the past, he held faculty positions at the University of Connecticut, Manitoba, and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 80 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 160 papers and abstracts to his credit.

Visit Dr. Sachdeva’s blog on http://drsachdeva-conference.blogspot.com. All doctors are invited to join the “Improving Orthodontic Care” discussion blog. Please contact improveortho@gmail.com for access information.

Volume 6 Number 1

designed with .017" x 025" CuNiTi AF 35ºC suresmile® precision archwires (Figure 6).

These were installed 6 weeks later. The patient was asked to wear anterior box elastics and concomitantly use Class 3 elastics. Also, at this appointment “turbos” were bonded on the lower first molars to help maintain the level of both the upper and lower molars. Elastic wear was continued over a period of 4 months while the precision archwire remained unchanged. A month later, the patient was debonded.

This was 9 months from the start of active treatment (Figure 7). The treatment objectives were met. Note the correction in the occlusal plane (Figure 8). Please see the superimposition of the Virtual Dental Simulation plan VDS to the Virtual Final Model VFM (Figure 9).

Figures 1A-1B: Patient BG. 20-year-old male patient presented with a Class 3 skeletal pattern with an increased facial height. The patient also demonstrated an open bite, a slightly constricted maxillary buccal segment, and a slight functional mandibular shift to the left. 1A. Initial intraoral photographs. 1B. Initial X-rays Orthodontic practice 13

ORTHODONTIC CONCEPTS

BioDigital Orthodontics Management of patients with open bite (2): part 13

ORTHODONTIC CONCEPTS VDM

Figures 2A-2C: Patient BG. 2A. Virtual Diagnostic Model (VDM). 2B. Virtual Diagnostic Model with mouth open. 2C. Virtual Diagnostic Model. Note the divergence in the maxillary and mandibular esthetic occlusal planes VDS-1 Functional

VDS-1 Functional and Dental

VDS (white) vs.

VDM (green)

VDS (white) vs. VDM (green)

Figures 3A-3E: Patient BG. Plan was designed in two steps. 3A. Virtual Diagnostic Simulation (VDS-1). In the first step, asymmetric mandibular shift correction was simulated. 3B. VDS-1 (white) vs. VDM (green). 3C. Virtual Diagnostic Simulation (VDS2). The second step simulated the correction of the occlusal plane, the archwidth, and the detailing of the occlusion. 3D. VDS-2 (white) vs. VDM (green). The maxillary functional occlusal plane was chosen as the treatment plane of occlusion. The upper and the lower esthetic occlusal planes were extruded to the level of this plane.

3E. Shows the nature and magnitude of displacements of the dentition

Figure 4: Patient BG. Shows the differential in the planned level changes between the upper and lower esthetic occlusal planes 14 Orthodontic practice

Volume 6 Number 1

ORTHODONTIC CONCEPTS

Figures 5A-5B: Patient BG. Mid-treatment therapeutic scan was taken 2.5 months from start of treatment. 5A. Mid-treatment photos and 5B. Mid-treatment panorex

VTM

VTS

Figures 6A-6E: Patient BG. 6A. Virtual Therapeutic Model (VTM). 6B. Virtual Target Setup (VTS) with suresmile precision archwire designed with .017" x 025" CuNiTi AF 35ยบC. 6C. VTM (blue) vs. VTS (white). 6D. suresmile precision archwire viewed against VTM. 6E. Shows the nature and magnitude of displacements of the dentition

Figures 7A-7B: Patient BG. The patient was debonded 9 months from the start of active treatment. 7A. Intraoral debond photos.

7B. Final X-rays 16 Orthodontic practice

Volume 6 Number 1

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ORTHODONTIC CONCEPTS VFM

Figures 8A-8C: Patient BG. 8A. Virtual Final Model (VFM). 8B. Mouth open view of VFM. Note the leveling of the occlusal planes and the slight curve of Spee in the lower arch.

8C. VFM shows that the anterior occlusal plane was treated to the maxillary functional occlusal plane as per the stated treatment objectives

VDS (white) vs. VFM (green)

Figure 9: Patient BG. The treatment objectives were met. Note the superimposition of the VDS (white) to the VFM (green)

Patient MN Patient MN, a 25-year-old female, presented with a skeletal Class 2 open bite, maxillary constriction, and severe crowding in the upper arch and moderate in the lower (Figure 10). The Virtual Diagnostic Model (VDM) shows that the upper and lower occlusal planes are divergent (Figures 11A and 11B). Also, on closer examination, one can see that both the left and right functional occlusal planes are flat (Figure 11C). Generally speaking, such planes are conducive to Class 2 correction with Class 2 elastic wear.

Figure 11D shows a cross-sectional view of the VDM occlusal planes. This view provides better visualization of the flat occlusal planes (Figure 11D).

Since the patient did not consent to surgery, a non-extraction approach to treatment was planned (Figures 12A and 12D).

The Virtual Diagnostic Simulation plan shows that the mandibular functional occlusal plane was selected as the treatment occlusal plane (Figure 12B). The lower esthetic occlusal plane was treated to this level (Figure 12C).

18 Orthodontic practice

The flat maxillary functional occlusal plane (a result of forward drift) was steepened to correspond to the mandibular functional occlusal plane. This correction also helped in Class 2 correction. The maxillary esthetic occlusal plane was treated to the corrected maxillary occlusal plane. The maxillary archwidth was also corrected with minimal dental movements (Figure 12F). This was feasible since the buccal segment did not show substantial dentoalveolar compensations (Figure 13). Also, the upper right lateral is peg shaped, and appropriate spacing was planned to restore the tooth to its final shape post treatment.

Treatment was initiated with .017" x .017" CuNiTi AF 35째C in the upper arch, and 016" x .022" CuNiTi AF 35째C in the lower arch (Figure 14A). The patient was asked to wear Class 2 and anterior box elastics as well. The patient was seen 1.5 months later (Figure 14B); it was apparent that the patient was not wearing the anterior box elastics, so the importance of wearing the elastics was reinforced at this appointment.

Treatment progress 3 months from start is shown in Figure 14C. Note that the bite is beginning to close, and significant alignment in both arches has been achieved. Also, note some Class 2 correction has been achieved.

The patient was seen 1 month later (Figure 14D). At this time, an impression was taken to fabricate an upper quad helix appliance to expand the buccal segments. The quad helix was installed 4 weeks later. Through the course of treatment, the patient was requested to continue wearing elastics (Figure 14E). In the 6th month of treatment, tip-forward springs (Sachdeva) were fabricated from .017" x .025" TMA and placed in the lower arch to aid with the extrusion of the lower esthetic occlusal plane. In the upper arch, the spring was placed unilaterally on the right to aid in the anticlockwise rotation of the upper esthetic occlusal plane (Figure 14F).

At month 7, a mid-treatment therapeutic scan was taken (Figure 15). The Virtual Target Setup and 017" x .025" AF 35째C suresmile precision archwires were Volume 6 Number 1

The patient was debonded 6 weeks later (Figure 18).

After debonding, the patient was referred to the general dentist to temporarily restore the upper-right peg lateral. The final intraoral photos post buildup of the peg laterals are seen in Figures 19A-19C. A veneer has been planned as a final restoration for the peg laterals. Also, the virtual final model post restoration is shown in VFM-2 is shown in (Figure 19D). Figures 19E-19F show the

correction of occlusal planes achieved (Reference model is VFM-2).The Virtual Diagnostic Simulation plan is superimposed against the Virtual Final Model (VFM-1), and one may note that the treatment outcome is similar to the planned simulation (Figure 20A). Also, a transverse clipping plane view through the molars VDM and VFM-1 shows good control of molar bucco-lingual inclination during treatment (Figures 20B and 20C).

Figures 10A-10B: Patient MN. A 25-year-old female presented with a skeletal Class 2 open bite, maxillary constriction, and severe crowding in the upper arch and moderate crowding in the lower. 10A. Initial intraoral photos. 10B. Initial X-rays VDM

Figures 11A-11D: Patient MN. 11A. Virtual Diagnostic Model (VDM). 11B. VDM with mouth open.

11C. Note the divergent upper and lower occlusal planes. Also, on closer examination, one can see that both the left and right functional occlusal planes are flat. Generally speaking, such planes are conducive to Class 2 correction with Class 2 elastic wear. 11D. Cross-sectional view of occlusal planes provides better visualization of the flat maxillary occlusal plane Volume 6 Number 1

Orthodontic practice 19

ORTHODONTIC CONCEPTS

designed (Figure 16). The archwires were inserted 1 month later. Note at this time in treatment, the quad helix was also removed, but the auxiliaries, i.e., tip-forward springs, were kept, and elastic wear continued. Bite turbos were bonded on the lower molars to stabilize the posterior occlusal plane (Figure 17A). Substantial progress in the correction of the anterior occlusal plane and Class 2 correction were noted a month post insertion of the precision archwires (Figure 17B).

ORTHODONTIC CONCEPTS VDS

VDS (with occlusal plane)

VDS (white) vs.

VDM (green)

Figures 12A-12F: Patient MN. A non-extraction approach to treatment was planned. 12A. Virtual Diagnostic Simulation. 12B. VDS the mandibular occlusal plane was chosen as the treatment occlusal plane. 12C. VDM shows the level of the functional occlusal planes relative to their respective anterior occlusal planes. 12D. VDS (white) vs. VDM (green). 12E. Shows the planned changes of the esthetic occlusal plane with respect to mandibular functional occlusal plane (treatment occlusal plane).

12F. Shows the nature and magnitude of displacements of the dentition

Figures 13A-13F: Patient MN. A cross-sectional view of the VDS (white) vs. VDM showing the planned correction of the occlusal plane. 13A. VDM. 13B. Maxillary functional occlusal plane shown. 13C. Mandibular functional occlusal plane shown. 13D. Correction of the maxillary functional occlusal plane cant shown. Note the change in the cant of the maxillary occlusal plane.

13E. The mandibular functional occlusal plane is maintained. 13F. VDS shows the final correction of the occlusal plane. The maxillary functional and esthetic plane was treated to this reference plane. Also, the mandibular esthetic occlusal plane was treated to the mandibular functional occlusal plane 20 Orthodontic practice

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ORTHODONTIC CONCEPTS

Figures 14A-14F: Patient MN. 14A. Treatment was initiated with .017" x .017" CuNiTi AF 35째C in the upper arch, and 016" x .022" CuNiTi AF 35째C in the lower arch. The patient was asked to wear Class 2 and anterior box elastics from the start of treatment. 14B. 1.5 months later, it was apparent that the patient was not wearing the anterior box elastics, so the importance of wearing the elastics was reinforced at this appointment. 14C. Three months into treatment, the bite is beginning to close, and significant alignment in both arches has been achieved. Also, some Class 2 correction is visible. 14D. The patient was next seen at 4 months. An upper impression was taken to fabricate an upper quad helix appliance to expand the buccal segments. 14E. The quad helix was installed at 5 months. The patient was asked to continue wearing elastics. 14F. The patient was seen at 6 months from start of treatment. Tip-forward springs (Sachdeva) fabricated from .017" x .025" TMA were placed in the lower arch to aid with the extrusion of the lower esthetic occlusal plane. In the upper arch, the spring was placed unilaterally on the right to aid in the anticlockwise rotation of the upper esthetic occlusal plane

Figures 15A-15B: Patient MN. Patient MN. Seven months in active treatment, the mid-treatment scan was taken. A. Mid-treatment photos. B. Mid-treatment X-rays Volume 6 Number 1

Orthodontic practice 21

ORTHODONTIC CONCEPTS VTM

VTS

Figures 16A-16E: Patient MN. 16A. Virtual Therapeutic Model (VTM). 16B. Virtual Target Setup (VTS) with suresmile precision archwire designed. 16C. VTS (white) vs. VTM (blue). 16D. Shows the nature and magnitude of displacements of the dentition. 16E. suresmile precision archwire viewed against VTM

Figures 17A-17B: Patient MN. 17A. Maxillary and mandibular suresmile precision archwires fabricated from 017" x .025" CuNiTi AF 35째C were inserted 1 month later. Note the quad helix was removed. However, tip-forward springs (017" x .025" TMA), anterior box elastics, and Class 2 elastic wear were continued (not shown). 17B. Class 2 correction has improved. Anterior box elastics are working in tandem with the suresmile archwires to extrude the maxillary and mandibular anterior occlusal plane VFM-1

Figures 18A-18C: Patient MN. The patient was debonded 6 weeks later. 18A. Intraoral photos at debonding. 18B. Virtual Final Model (VFM)-1 at debonding.

18C. X-rays at debonding 22 Orthodontic practice

Volume 6 Number 1

Figures 19A-19F: Patient MN. 19A. Final intraoral images showing restoration on the UR 2 peg lateral. 19B and 19C. Is a close-up view of the anterior teeth showing the transitional and final restoration of the upper right lateral incisor respectively. 19D. Virtual Final model-2 showing temporary restoration on the UR 2 peg lateral. 19E. An open-mouth view showing the correction of the occlusal planes. 19F. Note that the esthetic occlusal planes have been corrected to the mandibular functional occlusal plane, and the maxillary functional occlusal plane has been flattened VDS (white) vs. VFM (green)

Figures 20A-20C. Patient MN. 20A. Superimposition of the Virtual Diagnostic Simulation plan against the Virtual Final Model shows the planned objectives were met. 20B. Transverse clipping plane view through the molars of the VDM. 20C. Transverse clipping plane view through the molars (VFM-1) shows bucco-lingual axial inclinations of the upper molars were well controlled during expansion

Conclusions Successful correction of an open bite deserves that the clinician first considers its etiology and then design the appropriate therapeutic measures to treat the offending factors.

From a design perspective, it is very important to first establish the reference occlusal plane and then a treatment approach that will aid the correction of the deviant occlusal plane to the selected reference occlusal plane. It should be noted that steepening the occlusal plane by orthodontic treatment is not generally stable as it tends to flatten with time. However, in select patients, as described in this article, it is possible to achieve some success when there is a substantial dental component to the deviant occlusal plane.1, 5-18 OP

Acknowledgments We are also most thankful to Dr. Sharan Aranha, BDS, MPA, and Arjun Sachdeva for their immense support in the preparation of this manuscript.

Volume 6 Number 1

REFERENCES 1.

Sachdeva R, Kubota T. BioDigital orthodontics. Management of patients with open bite (I): Part 12. Orthodontic Practice US. 2014;5(6):22-31.

2.

Beane RA. Nonsurgical management of the anterior open bite: a review of the options. Semin Orthod. 1999; 5(4):275–283.

3.

Kondo E, Aoba TJ. Nonsurgical and nonextraction treatment of skeletal Class III open bite: its long-term stability. Am J Orthod Dentofacial Orthop. 2000;117(3):267-287.

4.

Kim YH. Anterior openbite and its treatment with multiloop edgewise archwire. Angle Orthod. 1987;57(4):290-321.

5.

White L, Sachdeva R. Transforming orthodontics: Part 1 of a conversation with Dr. Rohit Sachdeva, co-founder and chief clinical officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(1):10-14.

6.

White L, Sachdeva R. Transforming orthodontics: Part 2 of a conversation with Dr. Rohit Sachdeva, co-founder and chief clinical officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(2):6-10.

7.

White L, Sachdeva R. Transforming orthodontics: Part 3 of a conversation with Dr. Rohit Sachdeva, co-founder and chief clinical officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(3):6-9.

8.

Sachdeva R. BioDigital orthodontics: Planning care with SureSmile technology: Part 1. Orthodontic Practice US. 2013;4(1):18-23.

9.

Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: Part 2. Orthodontic Practice US. 2013;4(2):18-26.

10. Sachdeva R. BioDigital Orthodontics: Diagnopeutics with SureSmile technology (Part 3). Orthodontic Practice US. 2013;4(3):22-30.

11. Sachdeva R. BioDigital orthodontics: Outcome evaluation with SureSmile technology: Part 4. Orthodontic Practice US. 2013;4(4):28-33.

12. Sachdeva R. BioDigital orthodontics. Management of Class 1 non–extraction patient with “Fast–Track”©– six month protocol: Part 5.

Orthodontic Practice US. 2013;4(5):18-27.

13. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of Class 1 non–extraction patient with “Standard–Track©”– nine month protocol: Part 6. Orthodontic Practice US. 2013;4(6):16-26.

14. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of space closure in Class I extraction patients with SureSmile: Part 7. Orthodontic Practice US. 2014; 5(1):14-23.

15. Sachdeva R, Kubota T, Moravec S. BioDigital orthodontics. Management of Class 2 non–extraction patients (I): Part 8. Orthodontic Practice US. 2014;5(2):11-16.

16. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of patient with Class 2 malocclusion non–extraction (II): Part 9.

Orthodontic Practice US. 2014; 5(3):29-41.

17. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of patients with Class 2 malocclusion extraction (III): Part 10.

Orthodontic Practice US. 2014;5(4):27-36.

18. Sachdeva R, Kubota T. BioDigital orthodontics. Management of patients with Class 3 malocclusion: Part 11. Orthodontic Practice US. 2015;5(5):28-38.

Orthodontic practice 23

ORTHODONTIC CONCEPTS

VFM-2 Temporary restoration of UR2

PROPELLING ORTHODONTICS

Topical anesthesia and patient messaging Introduction from Peter Migneault, Propel Vice President:

This an exciting time in orthodontics as we have introduced a new technique into the mainstream that can allow clinicians to expedite tooth movement without compromising the quality of treatment. Over the coming year, we are thrilled to provide you with what we consider to be the critical components of Accelerated Orthodontics from both the clinical and practice integration perspective. For our first column, we’re proud to introduce Dr. Jonathan Nicozisis, a nationally recognized expert in Accelerated Orthodontics and the Propel technique. This first column in the six-part installment will provide in-depth insight into the ease of practical implementation of Propel in today’s orthodontic practice. Hope you enjoy the series!

S

o you have purchased your Propel devices and are staring at them wondering how to incorporate this into your office routine. How do I train my staff on the setup and delivery? What other supplies do I need? Before you can even get to that point, how do I discuss this with patients?

How can I efficiently and effectively frame the conversation?

This article will attempt to discuss what you need to know to seamlessly integrate Propel in your chairside procedures and discussions with patients, to proactively speed up overall treatment time or reactively to release stubborn movements with braces or aligners.

“Propelling Orthodontics” is more than simply moving teeth faster; it’s about propelling your office and making it stand out in your area. It is most impactful to harness the marketing aspects that Propel can offer you. Internal and external marketing efforts can easily pique interest for patients considering treatment who were reluctant to begin due to the potential length of treatment time.

Combine that with straightening teeth using aligners and not braces, and you have a marketing strategy like never before in our industry.

Here is an example of messaging during the initial exam for the “proactive” approach with Propel:

“I now have the ability to reduce your treatment time by almost half using Propel Orthodontics technology. With Propel, I use a strong gel on your gums for about 4 minutes and get you numb. I then manually create small dimples through the gums into the bone between the roots of the teeth. This stimulates the cellular activity and allows the bone to turn over faster; therefore, the teeth will move faster. I can have you switch your aligners out weekly instead of every 2 weeks.

There is no recovery time or swelling to deal with. The numbness wears off in about an hour, and you can go about your day without any disruption.”

For those patients that might be reluctant to use this method, I then continue to frame the conversation this way: “People go to plastic surgeons every day of the week and have acid peels, laser peels, and walk around like a burn victim for 2 weeks under a hat and big sunglasses so no one notices. Not to mention other plastic surgery procedures that produce swelling and bruising with much longer recovery periods that might be socially undesirable.

Initial

6 months Case 1: Twenty-five stages in 25 weeks to get the patient to refinement with two Propel treatments. Correction of a posterior crossbite in an adult. The case is not finished; these are progress images that show getting to refinement in half the time Jonathan Nicozisis, DMD, MS, has been in the specialty practice of orthodontics since 1999. He completed his dental education at the University of Pennsylvania before attending Temple University for his orthodontic residency. While at Temple University, Dr. Nicozisis received his specialty certificate in orthodontics and a master’s degree in oral biology. During his training, he also completed an externship at the Lancaster Cleft Palate Clinic in Lancaster, Pennsylvania, where he was involved with the care of patients with craniofacial syndromes. Dr. Nicozisis is a member of Invisalign® National Speaker’s Bureau and Clinical Research Network where he helps conduct research and development of new technologies and improvements to the Invisalign technique. Dr. Nicozisis is also the founding orthodontist and a scientific advisory board member of BAS Medical (now Corthera), a development stage company founded in 2003 with a mission to develop and market a novel technology to accelerate and improve the stability of orthodontic treatments. Dr. Nicozisis’ master’s research is the basis for BAS Medical innovative research. In February 2010, Corthera was acquired by Novartis. Dr. Nicozisis has been awarded membership to the Edward H. Angle Society of Orthodontists. He is a member of the American Association of Orthodontists, Middle Atlantic Society of Orthodontists, New Jersey Dental Association, Mercer County Dental Society, and the Greater Philadelphia Society of Orthodontists. Dr. Nicozisis is a paid lecturer, but not a consultant, for Propel Orthodontics.

24 Orthodontic practice

Volume 6 Number 1

Anesthesia A potential mental hurdle for the practitioner to get over is the notion of giving anesthesia as they may have not done this Initial

since dental school. This conversation is no throat. To prevent this, after the gel is applied, different than the one with the advent and use some have placed a cut/trimmed piece of of TADs in orthodontics. For those who are gauze over the gel to act as a mesh-scaffold not comfortable with a local infiltrative aneslatticework to help keep the gel in place. thesia, a profound gel from a compounding pharmacy can Option 2 be used as an alternative.

An alternative method The formulated topical for gel application is to trim pieces of gauze into strips and gel that is best is known as “The Baddest Topical in liberally apply the gel to the strips while they are on your Town (BTT 12.5).” Its ingrechairside unit. Using cotton dients are lidocaine 12.5%, tetracaine 12.5%, prilocaine pliers, those strips can then Needle-less application of gel 3%, and phenylephrine 3% be picked up and delivered to gel. Often used before laser procedures, desired area to be Propelled. View a tutorial gingivoplasty, and implant exposures, BTT at ortho-us.link/1BMHDA1 12.5 is a combination of three anesthetic Using this method, careful attention must ingredients and a vasoconstrictor. BTT 12.5 be paid to ensure clinical crowns do not interhas been used as an alternative to local fere and inadvertently remove some of the anesthetic injectable solutions. Depending gel from the gauze strips. This will decrease on local state laws, qualified staff may be the amount of gel being applied to the area delegated to apply the gel. and may prevent applying the gel to the unThere are a few methods to apply the attached tissue. gel. Staff can use a needle-less, disposable, After 4 minutes, use high-speed suction plastic syringe and draw up the gel from the to remove the gross amount of gel followed by wiping the tissues with wet gauze to bottle for easier application. It is not recomensure that all has been removed. It is normal mended to use a Q-tip to apply it as this has proven to be hard to manipulate the gel, and that the tissue becomes slightly blanched due often insufficient amounts are carried by the to the vasoconstrictor in the formulation.

It is recommended to allow the anesend of a Q-tip, so it has proven to be a less thetic to fully penetrate the periodontium for controllable method. another 10 minutes before proceeding with the Propel procedure.

Option 1 After the area to be Propelled is isolated Please follow proper Propel protocols and dried, the doctor or staff member can take related to sepsis control, location, and depth the filled disposable syringe and spread the gel selection as well as analgesic recommendaover the desired area while gently pressing the tions and repeating the procedure as needed. plunger with their thumb. It is recommended Although many are using topical exclusively in most areas of the alveolus, personally I that it be spread on both fixed and movable still use infiltration with my patients. More on mucosa. It is best to allow the gel to sit for 4 these topics in future editions of “Propelling minutes. It is important to monitor the gel to ensure it does not run into the back of the Orthodontics.” OP Final

Case 2: Treated in 5.5 months with 22 aligners, two Propel treatments, and Class 3 elastic on the right. Propel was applied in the upper and lower anterior and lower right quadrant only to better affect the Class 3 elastic forces. Case treated in five office visits including the initial exam. Final image is 6-month retention This information is sponsored and provided by Propel Orthodontics.

Volume 6 Number 1

Orthodontic practice 25

PROPELLING ORTHODONTICS

With Propel, there is none of this, and you get the result you want in half the time!”

The next question often is about the cost. Some offices charge a flat fee regardless of the number of Propel procedures.

Typically this flat fee is 7%-10% of the total treatment fee. Others frame the conversation by saying it is an additional $45 a month for the “X” number of months of treatment.

Do whatever it is you do currently in your practice when incorporating technologies into your treatment fee, keeping in mind that with Propel, you will also be significantly reducing the number of office visits to complete the case in a reduced amount of treatment time, thus increasing profitability per visit in a profound way.

Messaging for the “reactive approach” is similar in describing the procedure, but is slightly altered to address the given clinical situation (stubborn rotation or space closure).

An example of “reactive” messaging is, “As we can both see, it has been challenging to resolve this rotation (or close this space) over the last few appointments. To help facilitate the total correction and potentially cut out several office visits, I can use Propel to help temporarily soften the bone to better allow the teeth to move. It will only take a few extra minutes to perform.”

Some doctors charge a per procedure fee in cases like these while others do not as they realize the cost savings of correcting the movements in one visit compared to three to four visits to complete the same movements.

It is up to the discretion of the doctors to do what they feel is best.

CONTINUING EDUCATION

The fundamental objectives of early interceptive treatment Dr. Bradford Edgren discusses normalizing the dentofacial skeleton at an early age

E

arly interceptive treatment is orthodontic treatment performed at an early age during the early mixed dentition and before the establishment of the permanent dentition. Children as early as 6 years old can exhibit significant crowding, severe dentofacial discrepancies, and facial asymmetries. Patients that present with these problems are good candidates for early orthodontic/dentofacial orthopedic evaluation and treatment.

One of the fundamental objectives of early interceptive treatment is normalizing the dentofacial skeleton. Normalization of the dentofacial components involves creating adequate jaw size to accommodate the eruption of the permanent teeth, correction of facial asymmetries, and improvement in occlusal function. Leaving a patient untreated with a significant orthodontic disparity until after the eruption of the permanent teeth can result in a dental and/or skeletal discrepancy that is too severe to achieve an ideal or even an acceptable orthodontic result.

Consequently, an additional fundamental objective of early orthodontic intervention is the identification of abnormal jaw growth, specifically the excessive growth of the mandible. Recognition of such discrepancies and future growth prior to treatment can forewarn the orthodontist of specific problems to expect during treatment.1 Patients who exhibit signs of excessive mandibular growth require extended treatment, including early interceptive treatment, to reduce the effects of excessive growth and to harmonize future growth of both jaws.

Educational aims and objectives

This article aims to discuss the fundamental objectives of early interceptive orthodontic treatment.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 33 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize some fundamental objectives of early interceptive treatment.

• Identify early interceptive orthodontic treatment plans.

• Realize some consequences of delaying interceptive treatment.

• Recognize some specific elements for normalization of the dentofacial components.

Another objective is utilization of remaining future growth. By 7 years old, a child’s craniofacial skeleton has already achieved 75% of its total adult size. Ninety percent of the average child’s craniofacial development has been realized by age 12.2 Waiting until all the permanent teeth have erupted may significantly limit the utilization of future growth and dentofacial orthopedics due to the fact that the majority of dentofacial growth has already occurred.

Case report 1 This 7-year 5-month-old female presented with an anterior crossbite, deep overbite, a potential skeletal Class III due to the mandible and a right lingual crossbite (Figure 1). Her CBCT scan, taken on an i-CAT™ Next Generation scanner (Imaging Sciences International), and Ricketts’ cephalometric analysis, performed by Rocky Mountain Orthodontics® Data Services® (RMODS®), indicated a severe upper airway obstruction due to an enlarged

Table 1: Fundamental objectives of early intervention Normalization of skeletal dysplasias and asymmetries Promote appropriate jaw size to encourage the proper eruption of the permanent teeth Develop optimum alveolar bone support and appropriate buccal root torque/angulation for permanent teeth Recognition of upper airway obstruction and establishment of upper airway patency

Bradford Edgren, DDS, MS, earned both his Doctorate of Dental Surgery, as Valedictorian, and his Master of Science in Orthodontics from the University of Iowa, College of Dentistry. He is a Diplomate, American Board of Orthodontics, and a member of the Southwest Component of the Edward H. Angle Society. Dr. Edgren has presented nationally and internationally to numerous orthodontic groups on the importance of orthodontic diagnosis, early interceptive orthodontic treatment, CBCT, and upper airway obstruction. He has been published in AJO-DO, the American Journal of Dentistry, as well as other orthodontic publications. Dr. Edgren currently has a private practice in Greeley, Colorado.

26 Orthodontic practice

Improvement of occlusal function Intervention and termination of recalcitrant habits (i.e., thumb and finger sucking) Utilization of future growth Recognition of excessive growth, i.e. the mandible

Volume 6 Number 1

CONTINUING EDUCATION

Figure 2: Lateral 3D cephalometric image

Figure 1: 7-year 5-month-old female presenting with severe deep bite, anterior and right posterior crossbites

Figure 3: Lateral 3D cephalometric image with 3D airway analysis. Note the severe upper obstruction

Figure 6: Initial growth forecast to maturity without orthodontic treatment

Figure 4: Diagnostic lateral cephalometric tracing

Figure 5: Diagnostic frontal cephalometric tracing

adenoid pad and a skeletal lingual crossbite pattern due to the maxilla and mandible (Figures 2-5). Her growth forecast to maturity without treatment showed a significant amount of additional mandibular growth and counterclockwise rotation of the occlusal plane, deepening her already deep overbite (Figure 6). The panoramic image revealed an ectopic right maxillary canine with the potential for impaction with the canine overlapping the majority of the lateral incisor root (Figure 7).

Her early interceptive orthodontic treatment plan included rapid maxillary expansion, otolaryngologist referral for tonsillectomy and adenoidectomy, and fixed appliances.

Without early interceptive treatment, this patient would require orthognathic surgery to correct her severe skeletal Class III.

Figure 7: Diagnostic panoramic image demonstrating potentially impacting right maxillary canine

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CONTINUING EDUCATION

Figure 9: Interim deband 3D lateral cephalometric image

Figure 10: Interim deband 3D lateral cephalometric image with 3D airway analysis. Note the significant improvement in the airway volume with the concomitant straightening of the cervical spine

Figure 8: Interim deband photos

Figure 11: Interim deband lateral cephalometric tracing

Figure 12: Interim deband frontal cephalometric tracing

After 20 months of early interceptive treatment, her anterior and right posterior crossbites were corrected (Figure 8). Her skeletal Class III due to the mandible was eliminated, and her upper airway obstruction was removed (Figures 9-11). The skeletal lingual crossbite pattern that was present before treatment has been eliminated (Figure 12). Improvement in the volume of the upper airway following orthodontic expansion, tonsillectomy, and adenoidectomy resulted in significant straightening of the cervical spine.

After early interceptive orthodontic treatment, the revised future growth forecast to maturity without additional treatment no longer results in the severe skeletal Class III malocclusion (Figure 13). The interim deband panoramic image shows 28 Orthodontic practice

Figure 13: Interim deband revised growth forecast to maturity.

Note the more harmonious growth of both jaws because of early interceptive treatment

Figure 14: Interim deband panoramic image demonstrating the improved eruption path of the maxillary canines Volume 6 Number 1

open-bite pattern due to both jaws, adenoid blockage, a skeletal lingual crossbite pattern due to both jaws, and potentially impacting canines (Figures 16-21).

Several studies have shown that canines will palatally impact with adequate

arch length.3-5 A study by Al-Nimri, et al., suggested that excessive palatal width may contribute to the frequency of palatal canine impaction.6 In contrast, a study by Schindel and Duffy found that patients possessing a transverse discrepancy are more likely

Case report 2 Another 7-year 5-month-old female presented with severe crowding, maxillary constriction with a tendency toward left lingual crossbite, ectopic maxillary and mandibular lateral incisors, and an ectopic left maxillary first molar (Figure 15). Review of her CBCT imaging, as well as a lateral and frontal cephalometric analysis with future growth prediction, demonstrated a skeletal

Figure 16: Diagnostic lateral 3D cephalometric image Volume 6 Number 1

Figure 15: Diagnostic photos of a 7-year 5-month-old female with severe crowding

Figure 17: Diagnostic lateral cephalometric tracing Orthodontic practice 29

CONTINUING EDUCATION

a significant improvement in the eruption of the remaining teeth, especially the maxillary canines (Figure 14). Follow-up on this patient will require only comprehensive orthodontics, including maxillary and mandibular appliances, after the eruption of the remaining permanent teeth. Seven out of the eight fundamental objectives of early interceptive treatment were met with this patient, resulting in a very favorable outcome. Orthognathic surgery has been avoided, and the remaining treatment entails fixed orthodontic appliances to detail the occlusion and correct the midline discrepancy after the eruption of the remaining permanent teeth.

Permanent teeth can become impacted or begin impacting at an early age. Waiting until the remaining permanent teeth erupt can result in the inability to bring the ectopic and potentially impacting tooth/teeth into proper occlusion, ankylosis, and/or root resorption of adjacent teeth. Addressing impacting and ectopically erupting teeth early provides the opportunity to provide optimum alveolar bone support and appropriate buccal root torque/angulation, which leads to improved occlusal function.

CONTINUING EDUCATION

Figure 18: Diagnostic frontal 3D cephalometric image. Note the position of the maxillary lateral incisors and canines

Figure 20: Diagnostic lateral growth forecast to maturity

to have an impacted canine than those without.7 They also said that the best time to assess a patient for potential maxillary canine impaction is during the early mixed dentition. McConnell, et al., also found that patients with canine impactions demonstrated a profound transverse maxillary anterior arch deficiency.8 Miner, et al., stated that many patients may possess skeletal lingual crossbite patterns but dental compensations mask the existing transverse discrepancies.9 Many studies have suggested the extraction of the deciduous canine to encourage the favorable eruption of the palatally displaced canine.10-14 The mean age of the patients in these studies on palatally displaced canines ranged from 11.2 to 13.5 years of age at the period of the late mixed dentition. Bazargani, et al., found that a significant decrease in 30 Orthodontic practice

Figure 19: Diagnostic frontal cephalometric tracing demonstrating the skeletal lingual crossbite pattern

Figure 21: Diagnostic panoramic image illustrating the severe crowding and ectopic maxillary canines

arch length occurred in the extraction cases compared to controls. They also stated that maintenance of the maxillary arch length is important during the period of observation.14 Baccetti, et al., also found that the addition of cervical-pull headgear maintained the space available for maxillary canine eruption and, in fact, improved the rate of eruption of the canine to 87.5% compared to 65.2% in patients with just deciduous canine extraction.13 Power and Short and Olive’s investigations utilized fixed appliances in combination with deciduous canine extractions to encourage eruption of the permanent canine 62% and 75%, respectively.11,12 Furthermore, Power and Short stated that the final result of the deciduous canine removal was conditional upon the initial position of the permanent canine. If horizontal overlap

by the permanent canine of the lateral incisor exceeded half of the width of the incisor root, normal eruption of the permanent canine was unlikely.11 Extraction of the deciduous canines for this patient will not alleviate the severe dental crowding or the impending canine impactions. The previous studies were performed on patients with palatally displaced canines during the late mixed dentition. This patient presented during the early mixed dentition at age 7 years 5 months with midalveolar positioned canines. Extraction of the deciduous canines in this case would have resulted in loss of arch length, hence obstructing the proper eruption of the maxillary canines.

Moreover, success of the canine eruption in most of the previously mentioned studies was not based upon just the extraction of Volume 6 Number 1

Volume 6 Number 1

CONTINUING EDUCATION

the deciduous canine but also upon the existence of adequate space, or the creation of additional arch length with either fixed appliances or cervical headgear.

Studies by Baccetti, et al., and Schindel and Duffey have reported that rapid maxillary expansion is an effective treatment option for the early interceptive treatment of impacted maxillary canines.15, 16 Baccetti, et al., found that patients treated with rapid maxillary expansion had a successful eruption rate of 65.7% of palatally displaced canines, almost 5 times greater than that of the untreated controls (13.6%).15 Another study by Baccetti, et al,. stated that rapid maxillary expansion prior to the peak in skeletal maturation produces more pronounced transverse craniofacial changes at the skeletal level and circummaxillary structures.17 Rapid maxillary expansion following the pubertal growth spurt results in less skeletal and more dentoalveolar change.

The early interceptive orthodontic treatment plan designed for this patient included the following: • A referral to an otolaryngologist for tonsillectomy and adenoidectomy • Bonding of the maxillary arch initially to distalize the ectopic maxillary left first molar into proper position • Placing a bonded rapid maxillary expander with occlusal coverage after distalization of the maxillary left first molar to create arch length for the ectopic maxillary canines • Bonding of the mandibular arch with fixed appliances • A referral to an oral surgeon for canine exposure and guided eruption if the canines appear to be impacting The panoramic image shown in Figure 22 was made 17 months after the start of treatment on the day of the expander removal.

The maxillary dentition was bonded for 9.5 months before placing the rapid maxillary expander. The expander was activated for 2 weeks and then was left in situ for a total of 8 months. Following the removal of the rapid maxillary expander, the posterior segments of the maxillary arch were rebonded. The maxillary laterals and mandibular dentition were bonded 15 months into treatment.

Notice that even with maxillary expansion, the canines have both continued to move mesially. Obviously, even with the amount of treatment so far, impaction of the canines is inevitable. Thus, treatment should not be delayed for a patient presenting with these problems. Waiting could result in involvement of both the lateral incisor roots and possibly the left central incisor.

Figure 22: Progress panoramic image. Note the position of the maxillary canines

Figure 23: Interim deband photos

Total treatment time for this patient was 42 months to resolve the severe crowding, correct the lingual crossbite, improve the skeletal lingual crossbite pattern, and redirect the ectopically erupting canines; much longer than initially anticipated (Figures 23-28).

However, without early intervention, canine exposure and guided eruption techniques

would have been likely required to successfully bring the potentially impacting canines into occlusion. Moreover, the possibility of damage to the adjacent lateral incisor roots would have most likely occurred without early intervention. Seven of the eight fundamental objectives of early interceptive treatment were met in this successful treatment of this Orthodontic practice 31

CONTINUING EDUCATION

Figure 24: Interim deband 3D lateral cephalometric image

Figure 27: Interim deband frontal cephalometric tracing

complicated case. To capitalize upon future growth requires time to utilize. Consequently, the length of treatment for this patient is of the least concern when weighed against the success of the final outcome.

As demonstrated in these cases, the benefits of early interceptive treatment were important in the successful outcome in both of these patients. Early recognition of impacting teeth, skeletal dysplasias, upper airway obstructions, transverse discrepancies, and the potential for excessive growth provides for making knowledgeable orthodontic decisions and ultimately successful outcomes. OP

REFERENCES 1. Downs WB: Variations in facial relationship. Their significance in treatment and prognosis. Am J Orthod.

1948;34(10):812-840.

32 Orthodontic practice

Figure 25: Interim deband lateral cephalometric tracing

Figure 26: Interim deband 3D frontal cephalometric image

Figure 28: Interim deband panoramic image. Note the improved eruption path of the maxillary canines, the intact lateral incisor roots, and the lack of eruption of the right maxillary second molar due to the impacting third molar

2. Meredith HV. Growth in head width during the first twelve years of life. Pediatrics. 1953;12(4):411-429.

3. Jacoby H. The etiology of maxillary canine impactions. Am J Orthod. 1983;84(2):125–132.

4. Peck S, Peck L, Kataja M. The palatally displaced canine as a dental anomaly of genetic origin. Angle Orthod.

1994;64(4):249-256.

5. Zilberman Y, Cohen B, Becker A. Familial trends in palatal canines, anomalous lateral incisors, and related phenomena.

Eur J Orthod. 1990;12(2):135-139.

6. Al-Nimri K, Gharaibeh T. Space conditions and dental and occlusal features in patients with palatally impacted maxillary canines: an aetiological study. Eur J Orthod.

2005;27(5):461-5.

7. Schindel RH, Duffy SL. Maxillary transverse discrepancies and potentially impacted maxillary canines in mixed-dentition patients. Angle Orthod. 2007;77(3):430-435.

8. McConnell TL, Hoffman DL, Forbes DP, Janzen EK, Weintraub NH. Maxillary canine impaction in patients with transverse maxillary deficiency. ASDC J Dent Child.

1996;63(3):190–195.

9. Miner RM, Al Qabandi S, Rigali PH, Will LA. Conebeam computed tomography transverse analysis. Part 1: Normative data. Am J Orthod Dentofacial Orthop.

2012;142(3):300-307.

10. Ericson S , Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Eur J Orthod. 1988;10(4):283–295.

11. Power SM, Short MB. An investigation into the response of palatally displaced canines to the removal of deciduous canines and an assessment of factors contributing to favourable eruption. Br J Orthod. 1993;20(3):215–223.

12. Olive RJ. Orthodontic treatment of palatally impacted maxillary canines. Aust Orthod J. 2002;18(2):64–70.

13. Baccetti T, Leonardi M, Armi P. A randomized clinical study of two interceptive approaches to palatally displaced canines. Eur J Orthod. 2008;30(4):381–385.

14. Bazargani F, Magnuson A, Lennartsson B. Effect of interceptive extraction of deciduous canine on palatally displaced maxillary canine: a prospective randomized controlled study.

Angle Orthod. 2014;84(1):3–10.

15. Baccetti T, Mucedero M, Leonardi M, Cozza P. Interceptive treatment of palatal impaction of maxillary canines with rapid maxillary expansion: a randomized clinical trial. Am J Orthod Dentofacial Orthop. 2009;136(5):657-661.

16. Schindel RH, Duffy SL. Maxillary transverse discrepancies and potentially impacted maxillary canines in mixed-dentition patients. Angle Orthod. 2007;77(3):430-435.

17. Baccetti T, Franchi L, Cameron CG, McNamara JA Jr. Treatment timing for rapid maxillary expansion. Angle Orthod.

2001;71(5):343–350.

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The fundamental objectives of early interceptive treatment

A dual-arch protocol with accelerated movement and less discomfort

1.

Children as early as 6 years old can exhibit ________. a. significant crowding b. severe dentofacial discrepancies c. facial asymmetries d. all of the above

1.

Prostaglandins play an important role in the production of ________ and occur in almost all human tissues. a. inflammatory pain b. platelet production c. disposition towards caries d. curtailing of staphylococci

2.

By ____ years old, a child’s craniofacial skeleton has already achieved 75% of its total adult size. a. 7 b. 9 c. 10 d. 13

2.

They (prostaglandins) are biologically unusual because of their _________, their variety of form, and their short life span. a. ubiquity b. broad spectrum of physiological action c. high potency d. all of the above

EDGREN

3.

4.

5.

6.

Waiting until all the permanent teeth have erupted may _________ the utilization of future growth and dentofacial orthopedics due to the fact that the majority of dentofacial growth has already occurred. a. positively impact b. significantly limit c. have no effect on d. totally eliminate Waiting until the remaining permanent teeth erupt can result in _________. a. the inability to bring the ectopic and potentially impacting tooth/teeth into proper occlusion b. ankylosis c. root resorption of adjacent teeth d. all of the above A study by Al-Nimri, et al., suggested that excessive palatal width may contribute to the frequency of _________. a. Class II malocclusion b. improvement of occlusal function c. airway obstruction d. palatal canine impaction McConnell, et al., found that patients with

Volume 6 Number 1

________ demonstrated a profound transverse maxillary anterior arch deficiency. a. a lingual crossbite pattern b. an enlarged adenoid pad c. canine impactions d. adenoids 7.

Baccetti, et al., found that the addition of _________ maintained the space available for maxillary canine eruption and, in fact, improved the rate of eruption of the canine to 87.5% compared to 65.2% in patients with just deciduous canine extraction. a. cervical-pull headgear b. a Herbst appliance c. temporary implants d. bonding

8.

Furthermore, Power and Short stated that the final result of the deciduous canine removal was conditional upon the _________ of the permanent canine. a. decay level b. initial position c. pulpal condition d. none of the above

9.

Studies by Baccetti, et al., and Schindel and Duffey have reported that rapid maxillary expansion is ___________ for the early interceptive treatment of impacted maxillary canines. a. an ineffective treatment option b. not recommended c. an effective treatment option d. the only choice

10.

Rapid maxillary expansion following the pubertal growth spurt results in _________. a. less skeletal change b. more dentoalveolar change c. a profound skeletal change d. both a and b

SCHUDY/WHITE

3.

4.

5.

6.

Although _______ can reduce inflammation, it(they) does(do) not reduce the accompanying pain and often produce undesirable systemic side effects. a. antihistamines b. steroids c. adenosine d. both a and b All of the non-steroidal anti-inflammatory agents (NSAIDs) _____ prostaglandin synthesis via acetylation and inactivation of the enzyme cyclooxygenase. a. encourage b. inhibit c. accelerate d. double However, chronic reliance on NSAIDs will _______ bone metabolism and subsequently slow the movement of teeth. a. enhance b. accelerate c. curtail d. benefit The stasis of capillary blood flow contributes to postadjustment discomfort by producing arachidonic

acid, which makes tissues hyperalgesic, and some researchers have suggested that chewing on hard food could quell posttreatment discomfort by ___________. a. neutralizing the neural synapse b. exercising the periodontal membrane c. encouraging capillary vitality d. both b and c 7.

All of these studies confirmed the obvious; i.e., that the initial pain started a few hours after arch wire placement and abated over the next _________. a. 1-to-2 days b. 3-to-4 days c. 5-to-6 days d. 2 weeks

8.

After various weeks of the initial dual-arch wires, the annealed wires were removed, and the active NiTi wires were then free to work alone, and they _____. a. achieved alignments quickly b. achieved alignments slowly c. failed to achieve sufficient alignment d. did not reach the desired treatment goals

9.

At this point, one can only conjecture why such accelerated movement occurs with the dual-arch wire protocol. Perhaps a critical mass of osteocytic metabolism is marshaled but remains subdued until ___________. a. addition of the titanium wire b. removal of the annealed wire c. capillary activity is completed d. prostaglandins are supplemented

10.

This ____________ technique does decrease pain significantly, while at the same time greatly enhancing alignment. a. force-limiting b. dual-wire, force-modulating c. norepinephrine-limiting d. NiTi-adjusting

Orthodontic practice 33

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ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

A dual-arch protocol with accelerated movement and less discomfort Drs. George Schudy and Larry White discuss a way patients can have less pain with their gain Introduction Many times when searching for one effect, investigators will serendipitously discover another; e.g., Alexander Fleming, who intended to study characteristics of staphylococci and ended up discovering penicillin. The current presentation offers a similar instructive for orthodontic clinicians.

The original intention was to reduce patient discomfort by inserting two initial arch wires (Figure 1), one an annealed wire that would exert minimal tooth movement, and another small, round NiTi wire whose effectiveness would be partially or totally negated by the annealed wire. Patients did experience a dramatic reduction in post-bonding discomfort, but upon the removal of the force-limiting annealed wire, tooth movement accelerated in a remarkable manner, and alignment occurred more rapidly than expected.

The orthodontist against pain The English author Horace Walpole coined the word serendipity from the ancient name for Sri Lanka, Serendip. He explained that this name was part of the title of a fairy tale, called The Three Princes of Serendip.

As the three princes traveled, they continually made discoveries of things that they had no intention of finding. The accidental detection of accelerated tooth movement in an effort to reduce patient discomfort both surprised and delighted, but that effect never entered the original equation.

Orthodontists generally assume that patients will have a certain level of posttreatment discomfort that will diminish after a day or two — while true for some patients, others continue to suffer chronically, and this affects their cooperation throughout therapy.

George F. Schudy, DDS, MS, FACD, is in Private Practice of Orthodontics, Houston, Texas, and is Adjunct Professor of Orthodontics at The University of Texas School of Dentistry at Houston.

Larry White, DDS, MSD, FACD, is in Private Practice of Orthodontics in Dallas, Texas, and is Adjunct Professor of Orthodontics at Texas A&M University Baylor College of Dentistry in Dallas, Texas.

34 Orthodontic practice

Educational aims and objectives

This article aims to discuss a dual-arch protocol that can accelerate tooth movement and decrease discomfort.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 33 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some reasons for posttreatment discomfort.

• Realize how prostaglandins play an important role in the production of inflammatory pain.

• See the role of antihistamines and steroids in inflammation reduction.

• Realize some effects of various arch wires on discomfort.

• Recognize the possibility for accelerated movement and reduced discomfort as a result of the dual-arch wire protocol.

Figure 1

Some have sought to blame patients’ attitudinal traits for this lack of compliance,1-3 but more recent research indicates that genetic predisposition for sensitivity may play a large role in patients’ reluctance to help with their treatment.4-8 Prostaglandins play an important role in the production of inflammatory pain and occur in almost all human tissues. They were first discovered in high concentrations in the prostate glands of sheep, and this accounts for their name. They are biologically unusual because of their ubiquity, their broad spectrum of physiological action, their high potency, their variety of form, and their short life span.9-11 The release of prostaglandins greatly enhances the transmission of painful stimuli because they biochemically mediate the amount of cyclic AMP (adenosine monophosphate), which modulates norepinephrine at the neural synapse.12 The localized effect of prostaglandins explains why some analgesic drugs, such as aspirin, indomethacin, ibuprofen, phenylbutazone, and extracts

of aloe effectively combat prostaglandininduced pain.

Although antihistamines and steroids can reduce inflammation, they do not reduce the accompanying pain and often produce undesirable systemic side effects. All of the non-steroidal anti-inflammatory agents (NSAIDs) inhibit prostaglandin synthesis via acetylation and inactivation of the enzyme cyclooxygenase.13 However, chronic reliance on NSAIDs will curtail bone metabolism and subsequently slow the movement of teeth.14-17 The stasis of capillary blood flow contributes to post-adjustment discomfort by producing arachidonic acid, which makes tissues hyperalgesic, and some researchers have suggested that chewing on hard food could quell posttreatment discomfort by exercising the periodontal membrane and encouraging capillary vitality.18 Another went so far as to develop a plastic bite wafer that patients could chew on after orthodontic adjustments.19 While we have only empirical evidence that bite wafers benefit patients, many doctors and patients have enthusiastically endorsed their use.20

Arch wire placement Several researchers have sought to evaluate the effect of various arch wires on orthodontics patients, e.g., stainless steel, NiTi, thermal NiTi, etc.,21-27 while others have sought to measure patients’ psychosocial adjustments.28-31 Volume 6 Number 1

B

Figures 3A and 3B Figure 4: Pain Report Cards Figure 2: A maxillary arch with only the dead soft wire in place.

This wire usually extends to the first bicuspids

Recently researchers32-34 observed the discomfort of patients and the movement acceleration after using a low-level laser applied to the gingiva overlying teeth, while another group35 studied the effect of vibration of the teeth as a pain reliever. All of these studies confirmed the obvious; i.e., that the initial pain started a few hours after arch wire placement and abated over the next 3-to-4 days. None of the investigations have concerned themselves with the remedial effect of an annealed wire much less one combined with an active NiTi wire.

Maxillary and mandibular arch wire techniques A .014 annealed stainless steel arch wire was placed within the maxillary brackets and pressed lingually at each interproximal to assure pacificity (Figure 2). A .014 NiTi arch wire (Figure 3A) is layered over the first wire and ligated with elastomers with the hope that the annealed wire would negate the energy of the active NiTi wire. Since the mandibular teeth have smaller roots, the dead soft wire was an annealed .012 stainless steel arch wire that was adapted as with the maxillary dead soft wire, and a .012 NiTi arch wire was overlaid and ligated with elastomers (Figure 3B). Presumably, the combination of wires would decrease the force on the teeth and subsequently decrease patient discomfort, which in fact, did occur.

Discomfort measurements A clinical investigation gauged the effect of the dual-wire system on patients’ discomfort. Thirty randomly selected patients participated in the study and were bonded with identical Bi-Metric Appliances (American Orthodontics) that uses .016 slots on the anterior teeth and .018 slots on the posterior teeth. Fifteen of the patients received only a maxillary .014 NiTi wire, while 15 other patients received the dual-wires of a .014 annealed stainless steel with an overlay of a Volume 6 Number 1

Upper .014 NiTi Only Quite Bad

3, 8, 14

15

15

Not Too Bad

2, 4, 11

2, 3, 5, 6, 11, 14

9, 11

6, 9, 15

9, 15

Noticeable

1, 5, 6, 7, 9, 10, 12, 13, 15

1, 4, 7, 8, 9, 10, 12

4, 6, 7, 10

2, 7

6

13

1, 2, 3, 5, 8, 12, 13, 14

1, 3, 4, 5, 8, 10, 11, 12, 13, 14

1, 2, 3, 4, 5, 7, 8, 10, 11, 12, 13, 14

3

4

Not Significant Days

1

2

5

Figure 5: Pain Report Cards Upper .014 NiTi Over Preconditioning Quite Bad Not Too Bad

12

7

Noticeable

1, 2, 6, 7, 14

1, 5, 12

7

6,7

Not Significant

3, 4, 5, 8, 9, 10, 11, 13, 15

2, 3, 4, 8, 9, 10, 11, 13, 14, 15

1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14, 15

1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14, 15

1

2

3

4

Days

.014 NiTi. As with any subjective assessment of pain, clinicians have trouble obtaining objective measurements. But since pain is such an individual experience, researchers have an obligation to accept as true a patient’s evaluation regarding the intensity of the event. Figure 4 shows the pain sensations of the .014 NiTi-only group, and Figure 5 shows the pain sensations of the dual-wire group.

Five of the patients in the NiTi-only group had severe pain that endured 3 days. No patients in this category had insignificant pain. In contrast, no patient in the dual-wire group suffered severe pain, and nine patients testified to having insignificant discomfort.

Only two of the dual-wire patients admitted to pain that was “not too bad.” Nine dual-wire

1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 5

patients reported insignificant pain, whereas only one patient in the NiTi group reported insignificant pain.

Rapid movement This protocol obviously produces significantly more friction and binding than ordinary arch wires since the slot was smaller (.016), and the annealed wire may touch the surfaces of the bracket slot, the wings (when present), and even the labial surfaces of some teeth. This procedure was developed simply as an effort to provide patient comfort. Little movement was expected with the annealed wire in place. But, interestingly, even with the frictional resistance plus the force-diminishing effects of the annealed wire, the .014 NiTi in the maxillary Orthodontic practice 35

CONTINUING EDUCATION

A

CONTINUING EDUCATION arch (Figures 6A and 6B) and the .012 NiTi in the mandibular arch (Figures 7A and 7B) still had enough force to achieve measurable movement with the two wires in place.

After various weeks of the initial dual-arch wires, the annealed wires were removed, and the active NiTi wires were then free to work alone, and they achieved alignments quickly.

These representative patients treated with this dual-arch therapy illustrate the accelerated movement achieved with this protocol. The patient in Figure 6 used the dual-wires for 28 days (Figures 6A and 6B), and the NiTi wire then worked alone for 15 days (Figure 6C). The incisal irregularity initially measured 11 mm. The therapy resulted in an average of 7.3 mm of movement per month. The patient in Figure 7 wore the dual-arch wires for 30 days (Figures 7A and 7B), and the NiTi wire worked alone for 26 days (Figure 7C). The incisal irregularity initially measured 13 mm, and the rate of movement averaged 6.5 mm per month.

A previous publication36 concluded that an average movement of 3.0 mm-4.9 mm per month constituted a fast rate of movement.

Summary At this point, one can only conjecture why such accelerated movement occurs with the dual-arch wire protocol. Perhaps a critical mass of osteocytic metabolism is marshaled but remains subdued until removal of the

A

B

C

Figure 6A-6C: Patient age 11-years old. Incisal irregularity initially measured 11.0 mm. Treatment time 44 days (1.5 months).

Movement 7.3 mm per month.

A

B

C

Figure 7A-7C: Incisal irregularity initially measured 13.0 mm. Treatment time 56 days (2.0 months). Movement 6.5 mm per month.

annealed wire. Regardless of the reason for rapid tooth movement, patients experienced significantly less clinical discomfort, and that was the primary objective.

No one has described the experience of clinical pain better than Dr. Welden Bell,37 and he sums up the problem succinctly: “As a clinical symptom, pain is an experience that cannot be shared. It is wholly personal, belonging to the sufferer alone. Different individuals sensing identical noxious stimulation feel pain in different ways and react at different levels of suffering. It is impossible

REFERENCES 1. Herscher R. A Personality Inventory Related to Patient Cooperation in Orthodontics. Dallas, TX: Baylor University College of Dentistry; 1970.

2. El-Mangoury NH. Orthodontic cooperation. Am J Orthod. 1981;80:604-622.

3. Gabriel HF. Motivation of the headgear patient. Angle Orthod. 1968;38:129-135.

4. Chess S, Thomas A. Know Your Child. New York, NY: Basis Books Inc.; 1989.

5. Aron EN. The Highly Sensitive Person. New York, NY: Carol Publishing Group; 1996.

6. White L. A new oral hygiene strategy. Am J Orthod. 1984;86(6):507-514.

7. White LW. Pain and cooperation in orthodontic treatment. J Clin Orthod. 1984;18(8):572-575.

8. White LW. Toothbrush pressures of orthodontic patients. Am J Orthod. 1983;83(2):109-113.

9. Rhodus NL. Prostaglandins: promulgators of pain. Anesth Prog. 1979;26(3):73-75.

10. Arayne MS, Hassan SS. Prostaglandins: In pain and inflammation. J Pak Med Assoc.

1977;27(5):326-330.

11. Ferreira SH. Prostaglandins, pain and fever. J Nature. 1972;240.

12. Greenberg, S., et al.: Dental Clinics of North America, Philadelphia, W.B. Saunders Co, 1976.

13. Ferreira SH, Nakamura M, de Abreu Castro MS. The hyperalgesic effects of prostacyclin and prostaglandin E2. Prostaglandins. 1978;16(1):31-37.

14. Chumbley AB, Tuncay, OC. The effect of indomethacin (an aspirin-like drug) on the rate of tooth movement. Am J Orthod. 1986;89(4):312-214.

15. Chao CF, Shih C, Wang TM, Lo TH. Effects of prostaglandin E2 on alveolar bone resorption during orthodontic tooth movement. Acta Anat (Basel). 1988;132(4):304-309.

16. Sandy JR, Harris M. Prostaglandins and tooth movement. Eur J Orthod. 1984;6:175-182.

17. Wong A, Reynolds EC, West VC. The effect of acetylsalicylic acid on orthodontic tooth movement in the guinea pig. Am J Orthod Dentofacial Orthop. 1992;102(4):360-365.

18. Furstman L, Bernick S. Clinical considerations of the periodontium. Am J Orthod.

1972;61(2):138-155.

for one person to sense exactly what another feels.”

Since pain remains such a personal affair, orthodontic clinicians should not expect any particular remedy to have an unlimited successful application, but whenever, however, and with whomever, they can alleviate patient anguish, they should avail themselves of any and all correctives available. This dual-wire, force-modulating technique does decrease pain significantly, while at the same time greatly enhancing alignment. OP

23. Jones ML. An investigation into the initial discomfort cause by placement of an archwire. Eur J Orthod. 1984;6(1):48-54.

24. Scheurer PA, Firestone AR, Bürgin WB. Perception of pain as a result of orthodontic treatment with fixed appliances. Eur J Orthod. 1996;18(4):349-357.

25. Firestone AR, Scheurer PA, Bürgin WB. Patients’ anticipation of pain and pain-related side effects, and their perception of pain as a result of orthodontic treatment with fixed appliances.

Eur J Orthod. 1999;21(4):387-396.

26. Wang Y, Jian F, Lai W, Zhao Z, Yang Z, Liao Z, Shi Z, Wu T, Millett DT, McIntyre GT, Hickman J. Initial arch wires for alignment of crooked teeth with fixed orthodontic braces. Cochrane Database Syst Rev. 2010;14;(4):CD007859.

27. Fernandes LM, Ogaard B, Skoglund L. Pain and discomfort experienced after placement of a conventional or a superelastic NiTi aligning archwire. A randomized clinical trial. J Orofac Orthop. 1998;59(6):331-339.

28. Bloom RH, Brown LR Jr. A study of the effects of orthodontic appliances on the oral microbial flora. Oral Surg Oral Med Oral Pathol. 1964;17:658-667.

29. Brown DF, Moerenhout RG. Pain experience and psychosocial adjustment to orthodontic treatment of preadolescents, adolescents, and adults. Am J Orthod Dentofacial Orthop.

1991;100(4):349-356.

30. Ngan P, Kess B, Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. Am J Orthod Dentofacial Orthop. 1989;96(1):47-53.

31. Polat O, Karaman AI, Durmus E. Effects of preoperative ibuprofen and naproxen on orthodontic pain. Angle Orthod. 2005;75(5):791-796.

32. Lim HM, Lew KK, Tay DK. A clinical investigation of the efficacy of low level laser therapy in reducing orthodontic postadjustment pain. Am J Orthod Dentofacial Orthop.

1995;108(6):614-622.

33. Harazaki M, Isshiki Y. Soft laser irradiation effects on pain reduction in orthodontic treatment.

Bull Tokyo Dent Coll. 1997;38(4):291-295.

19. Musgrove, K.: Personal communication, 19722.

34. Doshi-Mehta G, Bhad-Patil WA. Efficiency of low-intensity laser therapy in reducing treatment time and orthodontic pain. Am J Orthod Dentofacial Orthop. 2012;141(3):289-297.

20. Hwang JY, Tee CH, Huang AT, Taft L. Effectiveness of thera-bite wafers in reducing pain. J Clin Orthod. 1994;28(5):291-292.

35. Kau CH, Nguyen JT, English JD. The clinical evaluation of a novel cyclical force generating device in orthodontics. Orthodontic Practice US. 2010;1(1):10-15.

21. Jones M, Chan C. The pain and discomfort experienced during orthodontic treatment: a randomized controlled clinical trial of two initial aligning arch wires. Am J Orthod Dentofacial Orthop. 1992;102(4):373-381.

36. Sebastian B. Alignment efficiency of superelastic coaxial nickel-titanium vs super elastic singlestranded nickel-titanium in relieving mandibular anterior crowding: a randomized controlled clinical study. Angle Orthod. 2012;82(4):703-708.

22. Jones, M. L. and Richmond, S.: Initial tooth movement: Force application and pain-a relationship? Am J Orthod. 1985;88(2):111-116.

37. Bell WE. Orofacial Pain. Classification, Diagnosis, Management. 4th ed. Chicago, IL: Year Book Medical Publishing; 1989.

36 Orthodontic practice

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ORTHODONTIST’S VIEWPOINT

Treating sleep disorders with oral appliances Dr. Ronald Perkins discusses symptoms of sleep disorders and his treatment protocol

A

n as an orthodontist since the early 1970s, I typically recommended the surgical removal of the enlarged tonsils and adenoids that caused airway blockage in young children. The results of this wellknown surgical procedure were immediate: Parents reported that their children were sleeping more restfully, with no snoring and were much easier to wake up in the morning.

Within a few months, parents would often say that their children’s schoolwork was improving, along with their health and attitude. After studying the work of Dr. Rolf Frankel and others,1,2,3 who speculated that form followed function and that mouth breathing could affect growth in children, especially regarding long face syndrome and the use of a vertical-pull chin cup therapy, I started using this therapy, along with the removal of tonsils and adenoids, palatal expansion, and mandibular advancement.

The pre- and posttreatment photos (Figures 1A-1D and 2A-2D) show the results: healthy children with the reduction and correction of this vertical growth problem.

Firsthand observations of sleep disorder symptoms As an orthodontist, I was aware of pediatric airway problems and sleep disorders but unaware of my own sleep disorder. I suffered with weight gain, fatigue, and loud snoring. Fortunately, an alert physician heard me fall asleep in his exam room and recommended that I get a sleep study. Soon after, I encountered an old friend from dental Ronald Perkins has a DDS, MSD in Orthodontics from Baylor University College of Dentistry.

He is a Diplomate of the American Board of Orthodontics, Fellow of the International College of Dentists, member of the American Association of Orthodontists, and member of the American Academy of Dental Sleep Medicine. A practicing orthodontist in the Dallas/Rockwall area, Dr. Perkins treats patients in many modalities, including Invisalign®, braces, and early treatment to prevent sleep apnea. He improved the design of a sleep apnea/snoring appliance to support the TMJ, a modification that has been more than 96% successful. His extensive experience in early treatment (ages 5-10), such as jaw development, expansion, and airway improvement, reduces sleep disorders in children, and prevents future sleep problems and the need for surgery in adults. He is passionate about recognizing, treating, and teaching others to be more aware of sleep disorders in young children and adults.

38 Orthodontic practice

Before

After

Before

After

Before

After

Before

After

Figures 1A-1D: Patient with long face syndrome, who wore her vertical pull chin cup during first-phase expansion treatment. Note the autorotation closure of the mandible

Figures 2A-2D: An example of a patient who had first-phase Herbst advancement and expansion and vertical chin cup.

Note how much healthier she looks in the posttreatment photos

school, Dr. Keith Thornton, inventor of the TAP® (Thornton Adjustable Positioner) appliance at a dental event, and he recognized my sleep disorder too. Within 2 weeks, I was fitted with the oral appliance.

My first night of sleep in the TAP appliance was an epiphany. Normally, I would hit the snooze button at least 2 times before I could get out of bed. But on this night, for the first time in my adult life, I woke up refreshed before the alarm sounded, without fibromyalgia, numb feet, or acid reflux. I also woke up in the same position and did not “tear up the bed” with my restless sleep. During the day, I was much more energetic. I now recognized a few of the many symptoms of sleep disorders.4,5,6 In the next few months, I lost approximately 40 pounds because I was burning more calories during my sleep, and I felt more like exercising. I began to record the changes after recognizing the symptoms that were improving in my life.

In the meantime, the oral appliance was working well, but my jaw joints were uncomfortable in the morning, so I decided to balance my own appliance to support the joints during sleep, which made me feel even better. Unfortunately, I waited a little too long to balance my appliance because I

had developed a Class III occlusion, an all too common side effect of oral appliances.

(This bite change is probably the main reason many dentists are reluctant to treat patients with oral appliances.)

Because my balanced oral appliance was so much more comfortable, I decided to treat all my patients who wore this in the same manner. The results seemed phenomenal, with very few side effects and without creating Class III occlusions. Across the board, I observed a reduction of my patients’ symptoms, as well as a reduction of their headaches. From 30 years’ experience and training in treating temporomandibular joint (TMJ) problems mostly with splints, I became more convinced of the effectiveness of this type of comprehensive treatment. In the past, I was really treating one of the major symptoms of sleep disorders, not the real cause, which is often the nightly clenching and bruxing that adversely affects the jaw joints. Now my goal is to treat the sleep disorder and the TMJ problems at the same time.

This drastic improvement in my life and near-death experience (I was holding my breath for a full minute and having oxygen desaturation of at least 50%), spurred me Volume 6 Number 1

How do oral sleep appliances work?

Even though there are many different types of appliances, the most commonly used mandibular advancement device (MAD) appliances, such as the TAP, work by slightly advancing the mandible and the tongue to a position forward enough to hold the airway open when the throat muscles relax, thereby preventing airway collapse during deep sleep. My preference from clinical experience is that these appliances should be custom-balanced to support the jaw joints during sleep so as to reduce side effects, such as headaches and bite change. In my practice, the TMJ-balanced TAP appliance and the AM Aligner are used for preventing unwanted bite changes. At the appliance delivery appointment, the AM Aligner (a lowheat ThermAcryl® wafer) is easily formed in the patient’s mouth to his/her normal occlusion or bite. The patient must use this bite wafer or AM Aligner every morning, usually for 10 to 15 minutes, to slowly and gently reposition the jaw back to the normal position (Figure 3).

Symptoms of sleep disorders The symptom list in Table 1 helps to detail the patient’s progress. For example, if

the patient is no longer snoring, waking up more refreshed, having no acid reflux, and no morning headaches, this illustrates that the appliance is working. I will also check for any joint symptoms and adjust the appliance as necessary.

Oral and facial symptoms, such as dark circles or bags under the patients’ eyes, also signal sleep disorders. An interview using the in-depth initial symptom list (Table 1) usually reveals many more symptoms.

Each patient is unique with his/her own particular set of symptoms. (I highly recommend my patients read an outstanding book called Sleep Interrupted by Steven Y. Park, MD, to help them understand their symptoms.) From my experience, many of the adult patients I interview are able to trace these sleep problems to their childhood.

The August 2012 edition of Pediatrics®, the official journal of the American Academy of Pediatrics, reported current clinical guidelines regarding childhood sleep disorders. In my opinion, orthodontists could play a very

important role, in collaboration with pediatricians and sleep physicians in helping young children with these problems using early orthopedic treatment.

Children can have slightly different symptoms than adults (Tables 2 and 3). Snoring in a child is a possible sign of airway obstruction.

Table 1: Symptom List Name:_________________________________________ Delivery Date:_______ Sleep Position:_____________ Observer:______________________________________

Follow-up Appointments Unrefreshed Snoring Stop Breathing Tiredness — Tired Eyes Restless Sleep Acid Reflux/Indigestion Fibromyalgia Backache Headaches High Blood Pressure Depression Wake up out of breath Jump when going to sleep Carpal Tunnel Syndrome Heart Problems Weight Gain Night Sweats No Dreams Clincher/Grinder

Figure 3: AM Aligner. The patient is directed to place the aligner on his/her lower teeth and slowly close into the upper teeth using the ramp created by the upper incisors. (See the red arrows). All patients who have MAD-type appliances would benefit from using the aligner every day for at least 15 minutes to return the jaw to its original position

Table 2: Survey of 10 Lifesaving Questions

TMD Syndrome

Table 1: Each patient is interviewed using this list to start the diagnostic process, which is then followed by the oral exam.

This list will be used at every treatment visit to evaluate each patient’s progress

Table 3: Survey of 10 Lifesaving Questions for Your Child

Do you snore?

___ Yes

___ No

Have you or anyone observed you stop breathing or gasp during sleep?

___ Yes

___ No

Does your child wake up tired and unrefreshed?

___ Yes

___ No

Do you wake up tired and unrefreshed?

___ Yes

___ No

Is your child a restless sleeper?

___ Yes

___ No

Do you doze off easily?

___ Yes

___ No

Is your child often tired and cranky?

___ Yes

___ No

Do you ever wake up out of breath, gasping or coughing?

___ Yes

___ No

Does your child have large tonsils?

___ Yes

___ No

Are you a restless sleeper?

___ Yes

___ No

Does your child have a retrusive lower jaw (no chin)?

___ Yes

___ No

Do you ever have indigestion or acid reflux?

___ Yes

___ No

Does your child have constricted dental arches (crowded teeth)?

___ Yes

___ No

Do you have headaches or jaw pain?

___ Yes

___ No

Does your child have dark circles under eyes (tired eyes)?

___ Yes

___ No

Do you have or ever had in the past high blood pressure?

___ Yes

___ No

Does your child wet the bed?

___ Yes

___ No

Do you ever have night sweats?

___ Yes

___ No

Does your child have frequent bad dreams?

___ Yes

___ No

Does your child snore?

___ Yes

___ No

Three (3) or more YES answers to these 10 questions means you should be further evaluated for SDB. Five (5) or six (6) YES answers means there is a very good possibility that you may have SDB.

Three (3) or more YES answers to these 10 questions means your child should be further evaluated for SDB. Five (5) or six (6) YES answers means there is a very good possibility that your child may have SDB.

Table 2: These questions offer a good start in screening adult patients for sleep disorders. As few as three positive responses should indicate the need for further evaluation

Table 3: Ten questions for children should be answered by the parents. As few as three positive responses should indicate the need for further evaluation

Volume 6 Number 1

Orthodontic practice 39

ORTHODONTIST’S VIEWPOINT

to start helping others with sleep disorders.

I began to recognize their symptoms, which were similar to mine. Along with reading the most current research in sleep medicine, I started to develop a comprehensive list of symptoms to evaluate and treat patients with potential sleep disorders. Many adult patients were referred to me for TMJ problems, and I began to recognize that many of those patients had symptoms of sleep disorders.7

ORTHODONTIST’S VIEWPOINT Consider these questions: Is the child a restless sleeper? Is the child often tired and/or cranky? Dark circles under a child’s eyes, or “allergic shiners,” may be a sign of sleep deprivation, just as in adults. Large tonsils, retrusive jaws, narrow or constricted dental arches, bad dreams, and bed-wetting may all point to sleep disorders as well.

The oral exam A simple oral dental exam can begin to show the clinician signs of bruxism, obstruction, and snoring. The oral exam should include checking for extremely heavy bone formation around the teeth, including tori and exostosis in many cases — a sign that patients may have been bruxing or clenching for a long time, perhaps since childhood.

Teeth obviously worn from bruxing and numerous crowns in older adults are also apparent signs in many patients. The next step is to look beyond the teeth into the posterior palatal areas and look for inflammation of the soft palate and uvula, possibly due to snoring or obstruction. There can also be inflammation of the oral pharynx due to acid reflux (see Figure 4). The size of the airway — small, medium, or large (Mallampati scores) — is also a determining factor. Tonsils should not be large enough to obstruct the airway.

The next step is the palpation of the muscles of mastication and TMJ areas to determine if the patient is clenching regularly or has pain coming from either jaw joint. Pressing orally behind the retromolar area will elicit severe pain in patients whose muscles are tense from bruxing or clenching, and many of these patients will have headaches behind their eyes. Next, using the stethoscope, I listen to the joints and evaluate crepitus and popping.

From my clinical experience, patients with medial pops and the history of locking seem more likely to have problems with an oral appliance.

After discussing the exam results with patients (who have obvious symptoms) and the benefits to their health of treating their sleep disorder, I would then request a sleep study, evaluated by a sleep physician, who will then make recommendations for treatment. Patients can choose between a home study or an overnight study in a clinic. State laws vary from state to state with regard to the dentist’s role in treatment and diagnosis of sleep disorders, so always be aware of your particular state’s practice rules and regulations.

Upper Airway Resistance Syndrome (UARS) is the first level of a continuum of sleep disorders (Figure 5) that starts with 40 Orthodontic practice

UARS and progresses through snoring, on to severe apnea.9,10,13 Many patients who snore or have UARS9,10,13 can be treated with a dental appliance. I see many patients with UARS who are just as miserable and sleep deprived as patients with severe apnea. The patients who have UARS just stop breathing enough to cause awakening, which disrupts the sleep cycle, causing clenching and bruxing of the teeth. Another typical symptom of patients is forgetting their dreams, or having no dreams or bad dreams.

With treatment, many patients start having memorable, vivid dreams — another positive treatment result for many patients, especially young adults and children.

If patients are ready to start, we will take routine diagnostic records (X-rays, photos, and appliance impressions). As a part of these diagnostic records, the standard

cephalometric X-ray also allows for a good view of the adenoid tissue in the upper airway, especially in children. My goal is to teach patients to monitor their sleep disorder by understanding their symptoms. I ask adult patients to record both their evening blood pressure and morning blood pressure for at least 3 days and bring that written record to their next appointment. In many cases, the patients with high blood pressure will often see a lowering of their pressure with treatment, especially in the morning. I have seen patients lowering blood pressure 10 points the first night they used their appliance, a good sign that treatment is working.

Another telling symptom is the tendency to jump or jerk when falling asleep. This often can be the first time the patient obstructs or snores, and they are immediately awakened.

Patients’ feedback indicates that wearing

Figure 4: This photo of a teenage patient at his retainer delivery is an excellent example of what can be seen beyond the teeth to the back of the throat. Notice inflammation of the soft palate and oral pharynx. This patient is always tired and had multiple symptoms of a sleep disorder

Understanding Sleep-Disordered Breathing Sleep breathing continuum UARS

Snoring

Sleep Apnea

Figure 5: Sleep disorders range from UARS (Upper Airway Resistance Syndrome) to snoring to sleep apnea. Many patients who do not have sleep apnea still can have a severe health problem that could be recognized and treated Volume 6 Number 1

Orthopedic/orthodontic treatment for young children needing airway development Now, as I look back at the many patients treated with the Herbst mandibular advancement appliance or with palatal expansion, also including mandibular uprighting expansion to enlarge the developing dental arches to create more tongue space, I realize that their improved health resulted from treatment similar to that of sleep disorders. Most children facially appeared so much healthier, and 20 years ago, I did not understand why this was such a common result. Orthopedic changes were creating more tongue space, as well as allowing the tongue to posture forward, just like an oral sleep appliance. I recognize now that advancing the mandible with the Herbst device has helped many young children breathe better at night. The parents have reported the dramatic results similar to those often seen with removal of tonsils and adenoids.

Along with expansion and mandibular advancement, in most of my patients who will cooperate, I use a vertical-pull chin cup not only to modify vertical growth but also to help the growing child use his/her airway.

Parents are very supportive when they understand what these appliances can do for their child’s long-term health. I learned early from several ENTs that if a person does not use his/her nose, the tissues will expand from this non-use. Therefore, in growing children, why not help them breathe through their nose and develop the upper airway?

Orthodontists could perform a major role in helping to prevent or reduce the incidence of sleep disorders with progressive early treatment by expanding arches and advancing mandibles or maxillas in some cases and increasing the airway. In my practice, the experience of treating patients with sleep disorders has greatly increased the importance of non-extraction treatment to create tongue space, which can best be accomplished when the child is young (7 or 8 years old). This could be the only time we can truly expand the airway and help the patients sleep better the rest of their lives.

Cases in point Another important fact to keep in mind when evaluating symptoms is that sleep disorders seem to run in families. In other words, as an orthodontist treating all age Volume 6 Number 1

Orthodontists could perform a major role in helping to prevent or reduce the incidence of sleep disorders with progressive early treatment by expanding arches and advancing mandibles or maxillas in some cases and increasing the airway.

groups and families, I have seen a strong correlation of multiple family members having sleep problems.15 Often, the parents would tell me that they had the same problems as a child that their offspring was experiencing.

For example, an 18-year-old previous patient returned because of a broken retainer; 4 years after I had completed his treatment, I noticed he was very tired, and after questioning him, I found he had numerous symptoms of a sleep disorder. I called his father, who I had treated for a sleep disorder 9 years earlier, to discuss his son’s issue. The father disclosed that the son had been involved in four automobile accidents, and he had fallen asleep while driving. Before I could get him into a sleep appliance, he had another wreck.

It is important to be aware of patients who are tired and cranky, yawn a lot, and always look tired during their orthodontic treatment. You might just help save a young teenager’s life.

Recognizing and treating patients with sleep disorders has truly been the most rewarding experience of my life. Being an orthodontist, which I have always loved, involves treating our patients often for 2 years or more to achieve that final result when the appliances are removed and the patient is really happy. When treating adult patients with sleep disorders, I often have patients return to my office in 1 week commenting, “This appliance has changed my life,” and they often have new attitudes.

Young mothers will often comment that they now have the energy to keep up with their children. If orthodontists can prevent a few more children from developing ADD, ADHD, and other cognitive problems by getting more oxygen to their developing brains,11,12,13 we can really make a difference and improve the quality of life for many people. OP

REFERENCES 1. Moss ML, Rankow RM. The role of the functional matrix in mandibular growth. Angle Orthod.1968;38(2):95-103.

2. Frankel R. The functional matrix and its practical Importance in orthodontics”. Rep Congr Eur Orthod Soc. 1969:207-218.

3. Harvold EP. The role of function in the etiology and treatment of malocclusion. Am J Orthod. 1968;54(12):883-898.

4. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP. Practice Parameters for the Treatment of Snoring and Sleep Apnea with Oral Appliances: An Update for 2005 [Report]. The American Academy of Sleep Medicine. SLEEP. 2006;29(2):240-243.

5. Beninati W, Harris CD; Herold DL; Shepard JW Jr. The effect of snoring and obstructing sleep apnea on the sleep quality of bed partners. Mayo Clin Proc. 1999;74(10):955-958.

6. Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, FJ Nieto, GT O’Connor, LL Boland, JE Schwartz, JM Samet. Sleep disordered breathing and cardiovascular disease: cross sectional results of the sleep heart health study. American Journal of Respiratory and Critical Care Medicine. 2001;163(1):19-25.

7. Colten HR, Altevogt BM, eds. Sleep disorders and sleep deprivation: an unmet public health problem. Washington (DC): National Academies Press (US); 2006. The National Academies Collection: Reports funded by National Institutes of Health.

8. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Ward SD, Sheldon SH, Shiffman, RN, Lehmann C, Spruyt K. Diagnosis and management of childhood obstructive apnea syndrome. Pediatrics. 2012;130(3):e714-755.

9. Guilleminault C, Stoohs R, Clerk A, Cetel M, Maistros P. A cause of excessive daytime sleepiness: the upper airway resistance syndrome. Chest. 1993;104(3):781-7.

10. Bao G, Guilleminault C. Upper airway resistance syndrome — one decade later. Curr Opin Pulm Med; 2004;10(6): 461-467.

11. Huang YS, Guilleminault C, Li HY, Yang CM, Wu YY, Chen NH. AttentionDeficit/Hyperactivity Disorder with Obstructive Sleep Apnea: A Treatment Outcome Study. Sleep Med. 2007;8(1):18-30.

12. Gottlieb DJ, Vezina RM, Chase C, Lesko SM, Heeren TC, Weese-Mayer DE, Auerbach SH, Corwin MJ. Symtoms of sleep-disordered breathing in 5 year-old children are associated with sleepiness and problem behaviors. Pediatrics. 2003:112(4):870-877.

13. Park SY. Sleep Interrupted. New York: Jodev Press; 2008.

14. Gilles L, Cistulli P, Smith M. Sleep Medicine for Dentists: A Practical Overview. Illinois: Quintessence Books; 2009.

15. Casale M, Pappacena M, Rinaldi V, Bressi F, Baptista P, Salvinelli F. Obstructive Sleep Apnea Syndrome: From Phenotype to Genetic Basis. Curr Genomics. 2009;10(2):119–126.

Orthodontic practice 41

ORTHODONTIST’S VIEWPOINT

the appliance promotes more restful sleep with much less insomnia (also a revealing symptom).

TECHNOLOGY

On the fence about new technology?

It might be time to dive in Dr. Adam Schulhof discusses the 3M™ True Definition Scanner for digital impressions

A

dopting any new technology in your practice can be challenging, whether due to finances, the need to change workflows, or any number of other factors. Some of us might think if we’ve been doing something a certain way for years with acceptable results, then there’s no reason to change.

Others might be interested in adopting a new technology, but are giving it time until the dust settles, and there’s a clear winner among competing products.

There comes a point, however, when a technology has been around long enough and is proven to be effective enough that even those who have been sitting on the fence should give it serious thought. For orthodontists, digital scanning is one such tool. While it still takes some adjustments in the practice to implement this procedure, the benefits in accuracy, efficiency, and patientfriendliness make it very worthwhile.

Patient comfort I have used a digital scanner in my orthodontic practices for about 2 years, beginning as a beta tester for 3M ESPE’s original scanner, which now has evolved into the 3M™ True Definition Scanner. Getting involved in digital scanning was a simple decision for me as an orthodontist. I knew that if you consider what many patients would list as the worst parts of the orthodontic process, having impressions taken Adam Schulhof, DMD, runs a state-of-the-art private practice in Oradell, New Jersey, utilizing only esthetic treatment options such as Clarity™ ADVANCED and Incognito™ appliance systems.

More recently, he established the Schulhof Center for Cosmetic Orthodontics, a practice that uses solely Lingual Appliances to provide esthetic and customized solutions for his patients. Dr. Schulhof is a recognized leader in the field of lingual orthodontics and lectures frequently in the United States and internationally. He is actively involved in research and development, continuing to improve and evolve esthetic and lingual orthodontics. Dr. Schulhof earned his DMD degree from the University of Medicine and Dentistry of New Jersey and was inducted into the Omicron Kappa Upsilon National Dental Honor Society. He attended Columbia University for his orthodontic specialty training. Dr. Schulhof is currently in the process of creating a Lingual Orthodontic Program for many universities in the United States.

42 Orthodontic practice

3M True Definition Scanner

would likely rank very high. This is particularly true for young patients who probably haven’t had an impression taken before and often have sensitive gag reflexes. Many times, the parents of these patients unintentionally make the situation worse by telling them about “those horrible molds” before the child starts treatment.

However, with a digital scanner, when parents come to my practice, there is a real “wow factor.” After seeing the scanner, many parents turn to their child and say, “You don’t know how good you have it!” The technology also has a great impact on referrals; while many practices might be similar

to one another, a digital scanner gives a parent a compelling reason to recommend your office to their friends. This focus on pediatric patients is not meant to exclude adult orthodontics wearers. They, too, are impressed with the technology, and since many have experienced a traditional impression in the past, they know firsthand the difference the scan can make for their comfort level.

Efficiency and consistency Beyond its benefits in patient comfort, a digital scanner gives an orthodontic practice an efficient, more consistent tool compared Volume 6 Number 1

Beyond its benefits in patient comfort, a digital scanner gives an orthodontic practice an efficient, more consistent tool compared to traditional impression material.

Two images, taken approximately 1 month apart, one pretreatment (above) and one during treatment with the braces on the teeth (below).

Understanding tooth movement A benefit that might not be top of mind when considering digital scanning is the ability to take mid-treatment scans with brackets and wires in place. With the traditional impression process, taking an impression during treatment can be very messy and often requires at least the removal of the archwire. Most orthodontists, myself included, opt to simply take photographs to create a record of movement and progress throughout the treatment process.

With a digital scan, the brackets and archwire are not an issue, and the scan can be taken just as it would be at the first appointment. These scans can be sent to the lab to produce an overlay that makes it possible to accurately track and understand tooth movement so that we can have an extremely exact reference point, instead of relying on observations using the naked eye.

To study the treatment that our patients are undergoing, my office is initiating a project where we will scan 20 patients at each visit to gain a comprehensive understanding of Volume 6 Number 1

tooth movement and how it occurs over time. Without a digital scanner, this wouldn’t be possible.

Patience and practice As with any new technique, digital scanning takes practice. I find that when my assistants are learning to use the scanner, they have an expectation that they should be learning faster. But I remind them that, just as it takes upwards of 20 traditional impressions to feel comfortable with that procedure,

digital scanning takes the same practice.

The difference is that, with digital scanning, their added practice will pay off in giving the patient a much more comfortable experience with highly accurate results.

The benefits of implementing this technology in my offices have convinced me that digital scanning is the future for orthodontists.

I would encourage practices that have yet to make the leap to look into their options and invest the time and energy in upgrading to this patient-friendly and efficient procedure. OP Orthodontic practice 43

TECHNOLOGY

to traditional impression material. My assistants can capture a typical scan in less than 2 minutes per arch, which is about the same amount of time that an alginate impression would take. The wand used with the latest version of the 3M True Definition Scanner has a very slim profile, which makes it easy to maneuver in patients’ mouths, even to the distal of the second molar.

Of course, accuracy is another huge benefit to digital scanning. The accuracy of a traditional impression is completely dependent not only on the clinician’s technique, but also on what happens to that impression once it is out of the mouth. Even if a flawless alginate impression is taken, if it is set aside for too long (as can happen on a busy day), distortions can easily set in. Contrast this with a digital impression, which shows the operator in real time if a scan is complete and accurate, and then can be transmitted to the lab in an instant.

Digital scans are also versatile, which opens the door to many workflows beyond orthodontics. The 3M True Definition Scanner has “Trusted Connections” — vetted integrations with manufacturers including 3M Unitek and Invisalign®, which means the technologies have been technically and clinically validated to work together. Beyond these options, the system can generate an STL file that can be sent to any open CAD/CAM system, so the user is not locked into any specific end products.

CLINICAL RESEARCH

Sleep apnea treatment: a survey investigating current orthodontic treatments and philosophies A study by Drs. Ryan Walter, Donald Rinchuse, and Daniel Rinchuse shows a wide range of responses on the treatment of OSA Abstract Objective The aim of this study was to survey orthodontists regarding the diagnosis, treatment, and outcomes of the treatment of obstructive sleep apnea (OSA).

Methods An email invitation from the American Association of Orthodontists (AAO), AAO Partners in Education, was sent to a random sample of the members of the AAO in the United States and Canada (n = 2,300), requesting participation in a 13-question online survey (SurveyMonkey®) regarding the diagnosis, treatment, and outcomes of the treatment of obstructive sleep apnea (OSA).

A reminder email was sent approximately 2 weeks after the initial email. A total of 175 orthodontists participated in the survey.

Results It was found that approximately 21% of the orthodontists that responded to the survey are carrying out some sort of sleep apnea therapy in their office. Of the doctors who treat sleep apnea, 42% initially attempt an oral appliance first with 7.9% combining this with a continuous positive airway pressure (CPAP) appliance. According to our survey, approximately 13% of apnea cases being treated in orthodontic offices are receiving surgical intervention. The survey led to a number of differing responses when examining the types of diagnostic tools that Ryan W. Walter, DMD, is a resident at Seton University Center for Orthodontics.

Donald J. Rinchuse, DMD, MS, MDS, PhD, is a clinical orthodontist in Greenburg, Pennsylvania.

Daniel J. Rinchuse, DMD, MS, MDS, PhD, is a Professor and Program director at Seton Hill Center for Orthodontics in Greensburg, Pennsylvania.

44 Orthodontic practice

are utilized to investigate reported cases of sleep apnea. Cephalometric analysis was the most commonly used radiographic examination, second only to clinical examination in diagnostic tools used. Cone beam computed tomography also was commonly used as a radiographic tool, with approximately the same diagnostic usage as photographic analysis. Diagnostic models were utilized only in approximately 29% of apnea cases in conjunction with other diagnostic tools.

Concerning outcomes of those who treated sleep apnea, only slightly greater than 50% perceived their success rate in patient treatment to be greater than 50%.

Conclusions This survey demonstrates that there is a great deal of variation in those treating sleep apnea, the methods with which they are diagnosing sleep apnea, and the outcomes of apnea treatment. Although many practitioners are referring out sleep apnea cases, according to the surveyed sample in our study, a significant percentage of orthodontists are treating this patient type. Further research and investigation into the optimal diagnostic tools, treatment types, and outcomes of treatment are needed.

Introduction Obstructive sleep apnea (OSA) has been receiving a great deal of attention in the contemporary medical environment.

Discussion about the condition has been increasing over the past 40 years. Estimates of the prevalence of obstructive sleep apnea have been variable, but the range can be fairly well estimated to be 2%-24%1,2,3 with most articles reporting somewhere around 8%1,2,3 of the U.S. population. The prevalence is estimated to be considerably higher in the male population3 as well as for those with higher body mass indices and excessive weight issues.4 The diagnosis and treatment of sleep apnea is a controversial topic in both the dental and orthodontic communities. Since this ailment is treated by both the medical as well as the dental community, there seems to be ambiguity regarding who should be the

primary supervisor of treatment, how apnea should be evaluated, and what treatment should be pursued. Due to the fact that many treatment modalities for this disorder mirror, or are the same as, many procedures utilized in orthodontics,5-9 it is logical to assume that orthodontists should be considered to be among the primary team members in the diagnosis and management of OSA. Many of the intraoral devices used in the advancement of the mandible as a means of improving airway volume are essentially the same devices used in Class II orthodontic correction. Additionally, oral and maxillofacial surgeons have adapted the Bilateral Sagittal Split Osteotomy (BSSO) and Lefort I with maxillary advancement, commonly referred to as telegnathic surgery when utilized in correction of apnea, as two of the most common surgical interventions used in orthognathic surgical correction of this condition. Even if surgical intervention were attempted with the intention of correcting only a sleep apnea problem, a considerable probability exists that orthodontic intervention would also be recommended to establish favorable post-surgical occlusion.

However, according to the literature, a lack of consistency exists regarding which specialists assume the roles of diagnostician and treating practitioner.

In addition to who should treat these patients and what role each should play in the treatment, there is a conflict about the diagnostic tools used to evaluate these patients.

Sleep studies, including the polysomnogram (PSG), have been fairly well established as the gold standard of clinically evaluating sleep apnea.10-12 However, in their systematic review and meta-analysis of the medical literature, Ross, et al., found “this systematic review of the best available evidence for diagnosis of sleep apnea suggests that although numerous diagnostic strategies have been reported …There is some evidence in a relatively small number of patients, that should be expanded with more studies, suggesting that a full laboratory PSG may not be necessary to diagnose SA.”1 Most case studies on the subject in the orthodontic and dental literature and most papers concerning Volume 6 Number 1

Volume 6 Number 1

of this disorder by surveying the treating population’s treatment modalities, diagnostic trends, results, and stability.

Materials and methods A 13-question survey was sent to a randomized sample of orthodontists across the U.S. via email through the AAO. Orthodontic residents and faculty from a university orthodontic program worked concomitantly to develop the 13-question survey. After the development of the questionnaire, the survey was tested with the residents, and some of the language and grammar of a number of the questions was modified. The survey consisted of nine questions pertaining to sleep apnea treatment and four demographic questions.

A finalized copy of the 13-question survey was generated using SurveyMonkey. The survey was then passed along to the AAO for approval. One question was modified to include a write-in answer. A finalized survey tool was created using SurveyMonkey. The AAO then sent a link to the survey to a random sample of 2,300 orthodontists who were members of the AAO. The survey link was first sent on August 19, 2014. Surveys through the AAO are sent only to a portion of the population to minimize research emails to the group’s population. On September 1, a second email was sent to the surveyed population to increase participation. Collection of responses was closed on September 16 after a total of 175 responses. After data collection, the survey instrument was utilized to compile responses into useful figures and charts. Hand tabulation was also done using an Excel spreadsheet document.

Results Of 2,300 emails sent to a random sample of orthodontists who are members of the AAO, 175 participated in the survey, amounting to a response rate of approximately 7.6%. The survey was completely anonymous. The important findings from the survey are shown in Table 1.

Approximately one-quarter of the responding survey participants are using some form of sleep apnea treatment in their offices with 35.5% believing that it is highly important for the orthodontist to be involved with treatment (4 or 5 on a 5-unit scale). Of those who treat sleep apnea, a significant portion treat only a very select segment of the presenting population — 42.3% treat less than 1% of those who present with sleep apnea, and 37.1% treat 1%-10% of the population of sleep apnea patients who present to their offices. Only 7.2% treated greater than 50% of the patients who presented to their office with OSA. In terms of diagnosis,

26.6% of the treating population of orthodontists attempted some intervention without completing a sleep study, 34.0% will not attempt any treatment at all without a sleep study analysis, and the remainder referred patients for sleep studies in certain cases, but not others that they treated. When analyzing the diagnostic tools used in evaluation of sleep apnea patients, 75% utilized a sleep study, 70% utilized a clinical exam, 58.8% utilized a cephalometric radiograph, 43.8% utilized computed tomography radiography, 43.8% utilized photographic records, and 28.8% utilized diagnostic models to aid evaluation.

Some other tools listed were at-home sleep tests, soft tissue analysis, rhinomanometry, tomography, and neck size. When examining those who utilized cephalometric analysis, it was found that 22.1% of practitioners did not trace their cephalometric radiographs and, thus, had no particular angle that they utilized to evaluate airway. The angle between the sella-nasion and mandibular plane was most commonly used to evaluate the airway with 21.2% of practitioners finding this the most useful cephalometric angle to evaluate sleep apnea patients. SNB was the second-most utilized angle for this purpose with 20.4% of practitioners utilizing it. The remainder of the angles examined — SN-PP, AFH, SNA, and ANB — all showed less than 10% of practitioners finding these most useful. Of those treating sleep apnea, oral appliances are utilized as initial treatment in 34.2% of cases in this study, continuous positive airway pressure machines were used in 10.5% of patients, and 7.9% utilized a combination of these two treatments. Surgical intervention was utilized in 13.2% of patients with 7.9% having two-jaw telegnathic surgery, and 5.3% being treated solely with mandibular advancement.

According to this survey, no patients were being treated with antidepressant therapy in orthodontic offices.

The perceived outcomes of those treating sleep apnea were as follows: • 20.9% believed they had a success rate between 0%-5%.

• 8.8% believed they had a success rate between 5%-25%.

• 15.4% believed they had a success rate between 25%-50%.

• 27.5% believed they had a success rate between 50%-75%.

• An additional 27.5% believed their success to be greater than 75%.

A chi-square test examined the demographic data and the treatment questions.

The examination revealed no correlation.

This indicates that there was no change in treatment, diagnosis, and perception of outcomes due to region, gender, board certification, or age.

Orthodontic practice 45

CLINICAL RESEARCH

the topic of apnea suggest having a sleep observation evaluation on apnea patients.12 Although it would be difficult to justify any type of nonreversible type of intervention, including surgical intervention, without a proper sleep observation evaluation, it is conceivable that orthodontists may attempt reversible interventions such as passive oral appliances or continuous positive airway appliance (CPAP) appliance therapy to treat a portion of the population. Due to the high cost of PSG evaluation, the limited access to such evaluations in some areas, and many patients’ general resistance to undergo such testing, a percentage of the population will not receive a sleep study evaluation. Some researchers and practitioners have developed other instruments to evaluate potential apnea patients. Some claim that a clinical examination will discover many features, and this is important to the diagnosis of patients, particularly children.13 Additionally, cone beam computed tomography has been fairly well adopted as the best imaging modality to evaluate the airway.14,15 However, there also have been several proposed cephalometric analyses to examine the airway.16 Pracharktam, et al., found that cephalometric analysis could be utilized to identify apnea patients previously diagnosed through sleep study procedures (respiratory disturbance index >20).17 Shen, et al., more recently suggested several analyses of cephalometric measurements to evaluate obstructive sleep apnea.18 The proposed analyses utilized several commonly used landmarks, as well as several landmarks not commonly used in orthodontic practices, to help diagnosis apnea patients.

Many practitioners utilize a combination of radiographic, photographic, and clinical evaluations to make an assessment before considering treatment of apnea patients.

In addition to the various forms of diagnosis of apnea patients, there are also several proposed treatment modalities for apnea, and many underscore the need for telegnathic surgical intervention with maxillary and/or mandibular advancement. Others are proponents of removable oral appliances utilized to advance the jaw and, thus, open the airway. Still others utilize a CPAP machine in the treatment of sleep apnea. Combinations of different therapies also are often used. The literature suggests a broad range of reported success in any given treatment modality, as well as an equally broad range regarding the stability of results.5-9 This discipline of dental sleep medicine includes a disparity of evidence-based findings and significant variance in diagnostic and management protocols. This study assesses the current trends in treatment

CLINICAL RESEARCH Table 1: Results of a 13-question survey of orthodontists on the topic of obstructive sleep apnea Topic

Results

18 to 28 29 to 34 35 to 50 51 to 64 65 or older

0.6% 14.4% 33.3% 35.1% 16.7%

Male Female

81.6% 18.4%

Southern Mid-Atlantic Pacific Coast Southwestern Northeastern Great lakes Midwestern Rocky Mountain

18.4% 8.0% 23.0% 9.8% 12.1% 13.2% 10.9% 5.2%

4. Board-certified

Yes No In process of attaining certification from board

43.6% 46.0% 10.3%

5.

Population perceived to suffer from sleep apnea

0%-1% 2%-5% 6%-10% 10%-20% >20%

1.7% 20.2% 28.9% 34.1% 15.0%

On a scale of 1-5, how important is it for orthodontists to be involved in the treatment of sleep apnea?

1 (not important) 2 3 4 5 (Highly important)

8.1% 19.2% 37.2% 16.9% 18.6%

What is the most useful cephalometric angle in the assessment of the airway?

SNA SNB ANB SN-MP SN-PP AFH I do not use cephalometrics as a diagnostic tool.

I use a cephalometrics, but do not trace them.

0.9% 20.4% 8.8% 21.2% 7.1% 3.5% 15.9% 22.1%

8.

What role do you as the orthodontist play in the diagnosis and treatment of sleep apnea patients?

I refer all patients back to the general practitioner and treat according to the GP’s recommendations.

I diagnosis and proceed with care in all cases of sleep apnea w/o the aid of the general practitioner.

I treat mild cases of sleep apnea with appliance therapy. I refer more severe cases.

I refer all patients to specialist.

I do not treat sleep apnea.

Other

5.2% 6.3% 14.4% 25.3% 37.9% 10.9%

9.

How often do you refer a patient for a sleep study assessment when attempting to treat a potential sleep apnea patient?

1 (never) 2 3 4 5 (always)

26.6% 21.3% 6.4% 11.7% 34.0%

10. What percentage of patients that present with signs or symptoms of sleep apnea do you treat?

Less than 1% 1%-10% 11%-50% Greater than 50%

42.3% 37.1% 13.4% 7.2%

11. What clinical and radiographic diagnostic tests do you require when diagnosing and treating sleep apnea? (Check all that apply.)

Clinical examination Cephalometric radiograph CT scan of airway Photographic records Diagnostic models Sleep clinic evaluation Other

70.0% 58.8% 43.8% 43.8% 28.8% 75.0%

12. What would your initial treatment be for a patient presenting with previously diagnosed sleep apnea?

Oral appliance CPAP — Continuous positive airway pressure appliance Referral to another provider/ No treatment Two-jaw telegnathic surgical advancement intervention Single-jaw telegnathic surgical mandibular advancement Treatment with antidepressant therapy Combination of an oral appliance and CPAP Other (please specify)

34.2% 10.5% 34.2% 7.9% 5.3% 0.0% 7.9%

13. In treating patients with sleep apnea, what do you believe your success rate to be?

0%-5% 5%-25% 25%-50% 50%-75% >75%

20.9% 8.8% 15.4% 27.5% 27.5%

1.

Age

2. Gender

3.

6.

7.

Region of practice

46 Orthodontic practice

Volume 6 Number 1

The results of this survey demonstrate that a significant number of orthodontists are involved in the treatment of sleep apnea. However, as predicted, the diagnosis, treatments, assessment, and protocols surrounding the efforts of these treating practitioners are highly variable.

Many practitioners in this survey believe the prevalence of the condition to be much greater than it is generally reported in the literature.1-4 Approximately 50% (49.1%) of the orthodontists surveyed believed prevalence to be as high as 10% or greater, which according to much of the research, is fairly high.19 This perception may be due to the recent interest in this condition, which seems to be increasing over the past 10 to 20 years as more information is discovered about the condition. This interest has translated to an increasing number of articles, as well as dental involvement in the field.

In addition to the inflated perception of sleep apnea prevalence, a large portion of the orthodontic community who completed the survey believed that it was highly important for orthodontists to be involved in the treatment of sleep apnea patients — 35.5% scoring either a 4 or 5 on a scale of 1-5 for how important it was for orthodontists to be involved in treatment. With many of the treatment modalities of sleep apnea affecting occlusal relationships, it seems like a logical idea that the orthodontist should be involved in treatment of this ailment.6-9 The following aspects have yet to be established: • Whether or not the orthodontist should be the primary treatment coordinator • Who should initiate treatment • Who should follow through with the course of treatment • Who should follow up with the patient • If the orthodontist should simply evaluate for possible changes in occlusion and/or modify the occlusion to assist with treatment as someone else generally dictates the overall treatment plan The orthodontist’s level of involvement currently will likely be dictated by the scope of the particular practice. While over one-third of respondents believe that the orthodontist should be involved in sleep apnea treatment, approximately one-quarter of orthodontists, 27.3%, believe that orthodontists’ involvement is of little or no importance in treatment of sleep apnea patients (a rating of 1 or 2 on the 5-point scale). Since general dentists Volume 6 Number 1

A logical first step in creating uniformity in sleep apnea treatment within the dental profession is the augmentation and development of specific guidelines and curricula in dental schools for the orthodontic community. and oral surgeons also are trained in occlusion and capable of determining when occlusion may need to be modified, orthodontic cooperation may be redundant. However, treatment by an MD, e.g., a primary care physician, pulmonologist, ear, nose, and throat specialist, etc., may necessitate a greater involvement by orthodontists in order to give patients comprehensive medical and oral care.

When considering the cephalometric evaluation orthodontists use for sleep apnea patients, there was no clear consensus as to which angles were most useful. However, SN-MP and SN-B were cited as most useful with 21.2% and 20.4% of the surveyed orthodontist population utilizing them respectively. Clearly, a high level of variability exists among those who use cephalometric measurements, as well as those who use cephalometric radiographs generally. In addition to the choices given, there were a large number of write-in responses as well as a significant portion of those who take cephalometric radiographs but do not trace them.

This study did, however, show that a number of orthodontists used cone beam computed tomography to analyze the airway. Although the research suggests that cephalometric radiographs can be effective in helping to analyze sleep apnea patients, current research suggests that cone beam computed tomography provides for a much better visualization tool.14,15 This raises the issue of clinicians’ need to expose these patients to minimal radiation. Most respondents support using CBCT scans for diagnosing sleep apnea patients; research agrees.14,15 Only approximately 20% of respondents perform any sort of sleep apnea therapy in their offices, which is interesting because most apnea treatment involves occlusal changes or, at the least, occlusal monitoring. Regarding referrals, most orthodontists refer to ear, nose, and throat specialists, oral surgeons, or pulmonologists in lieu of general dentists if further therapy apart from orthodontics is needed.

The term “diagnose” offers problems in

this survey. In order to properly diagnose sleep apnea, clinicians need a sleep study.9,11 So many of our respondents were correct when they wrote responses that alluded to the necessity of sleep studies to properly diagnose sleep apnea. A more appropriate term perhaps would have been “evaluation” or “examination” for intended treatment.

Perhaps some criticism is due in our profession for initiating therapy without a complete diagnosis. This survey clearly indicates that some practitioners fail to attain a full sleep study for each perceived obstructive sleep apnea patient. However, a substantial portion of the population would go untreated for this ailment if a full sleep study was required for every case. Also, some less severe apnea patients can be treated with noninvasive therapies without a sleep study diagnosis. A similar cursory diagnosis and treatment plan has been proposed and is currently used in the treatment of temporomandibular joint disorders.20 It is beyond the scope of this study to determine if this type of proposed treatment and diagnosis protocol is appropriate; however, perhaps orthodontists can research this further.

The survey demonstrates that orthodontic practitioners are using a variety of treatment modalities. With exception of antidepressant therapy, orthodontic practitioners are utilizing most mainstream treatments for sleep apnea today.6-9,21-25 Oral appliances are the number one treatment used by orthodontic practitioners. These appliances are fairly noninvasive and generally offer reversible effects, with the exception of some occlusal changes.24 In the authors’ opinion, this seems like acceptable treatment without a full diagnostic sleep study protocol, just as an occlusal guard may be used to alleviate idiopathic temporomandibular disorder.

Additionally, it is not surprising that orthodontists often endorse surgery for sleep apnea patients. Although many of these patients may be treated solely for apnea, it is possible that some may need simultaneous correction of malocclusions. For example, a severely Class II patient with a retrognathic mandible and apnea would benefit from orthognathic Orthodontic practice 47

CLINICAL RESEARCH

Discussion

CLINICAL RESEARCH advancement of his/her mandible. It is interesting that orthodontists recommend and use continuous positive airway pressure machines so readily. Training on how to utilize these machines is typically not part of the orthodontic or dental school curricula.

The use of this device illustrates how popular the subject has become, and a substantial portion of the respondents have sought further training.

The respondents in this study illustrate a generalized interest in sleep apnea among orthodontists regardless of gender, age, board certification, or demographics. This issue is widespread, and interest is growing across all groupings within the dental profession.

This survey, of course, has some flaws, e.g., the small percentage of the total population surveyed (7.6%), which only scratches the surface of this topic. Clearly, further research is warranted.

• Orthodontists are using variety of different tools to evaluate sleep apnea, including sleep studies, clinical examination CT scans, and cephalometric radiographs.

• Orthodontists use a variety of different therapies to treat sleep apnea, including oral appliance therapy, CPAP therapy, surgery, and combinations of these treatments.

• Many orthodontists do not treat sleep apnea and simply refer these patients to medical professionals for care.

• There were no differences in treatment, examination, or perceived

outcomes due to gender, age, location, or board-certification status.

• There is a high level of variation within our profession concerning sleep apnea treatment, and further research and guidelines need to be established as a guide for orthodontists. OP

Acknowledgments

The authors of this article extend a special thank you to Drs. Charles Greene, Sanjivan Kandasamy, and John Stockstill for their assistance in the development of the survey.

REFERENCES 1. Ross SD, Sheinhait IA, Harrison KJ, Kvasz M, Connelly JE, Shea SA, Allen IE. Systematic review and meta-analysis of the literature regarding the diagnosis of sleep apnea. Sleep. 2000;23(4):519-532.

2. Punjabi N. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):136-143.

3. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230-1235.

4. Young T, Peppard P, Gottlieb D. Epidemiology of Obstructive Sleep Apnea. Am J Respir Crit Care Med. 2002;165(9):1217-1239.

Conclusions This survey shows that orthodontists are involved in sleep apnea treatment and that controversy abounds regarding the evaluation and diagnostic criteria required for diagnosis and treatment. Additionally, it is clear that treatment outcomes are highly variable. Little consistency in any facet of sleep apnea treatment exists among the survey respondents. This is likely due to a lack of consensus and a lack of instruction about sleep apnea in dental schools and residency programs. A logical first step in creating uniformity in sleep apnea treatment within the dental profession is the augmentation and development of specific guidelines and curricula in dental schools for the orthodontic community.

The respondents in this survey demonstrated the following: • At least 20.7% of orthodontists who responded to the survey are currently carrying out some sleep apnea treatment.

• Generally, orthodontists are neutral about their need to be involved in treatment (37.2% indicated a grade of neutral on a 5-point scale).

• Generally, orthodontists believe the prevalence of sleep apnea is greater than reported in the literature.

• Approximately 50% of respondents believe their treatment has a greater than a 50% success rate, and approximately 50% believe their treatment has a lower than 50% success rate.

48 Orthodontic practice

5.

Rose EC, Barthlen GM, Staats R, Jonas IE. Therapeutic efficacy of an oral appliance in the treatment of obstructive sleep apnea: a 2-year follow-up. Am J Orthod Dentofacial Orthop. 2002;121(3):273-279.

6. Jacobson RL, Schendel SA. Treating obstructive sleep apnea: the case for surgery. Am J Orthod Dentofacial Orthop.

2012;142(4):435, 437, 439, 441-442.

7. Cozza P, Ballanti F, Prete L. Overview a modified monobloc for treatment of young children with obstructive sleep apnea. J Clin Orthod. 2004;38(4):241-247.

8. Rider EA. Removable Herbst appliance for treatment of obstructive sleep apnea. J Clin Orthod. 1988;22(4):256-257.

9. Lowe AA. Treating obstructive sleep apnea: the case for oral appliances. Am J Orthod Dentofacial Orthop. 2012;142(4):434, 436, 438, 440.

10. Flemons WW, Littner MR, Rowley JA, Gay P, Anderson WM, Hudgel DW, McEvoy RD, Loube DI. Home diagnosis of sleep apnea: a systematic review of the literature. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Chest. 2003;124(4):1543-1579.

11. Collop NA, Anderson WM, Boehlecke B, Claman D, Goldberg R, Gottlieb DJ, Hudgel D, Sateia M, Schwab R; Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3(7):737-747.

12. Silber M, Ancoli-Israel S, Bonnet M, Chokroverty S, Grigg-Damberger M, Hirshkowitz M, Kapen S, Keenan S, Kryger M, Penzel T, Pressman M, Iber C. The visual scoring of sleep in adults. J Clin Sleep Med. 2007;3(2):121-136.

13. Huynh NT, Morton PD, Rompré PH, Papadakis A, Remise C. Associations between sleep-disordered breathing symptoms and facial and dental morphometry, assessed with screening examinations. Am J Orthod Dentofacial Orthop. 2011;140(6):762-770.

14. EI AS, EI H, Palomo JM, Baur DA. A 3-dimensional airway analysis of an obstructive sleep apnea surgical correction with cone beam computed tomography. J Oral Maxillofac Surg. 2011;69(9):2424-2436.

15. El H, Palomo JM. Measuring the Airway in 3 dimensions: a reliability and accuracy study. Am J Orthod Dentofacial Orthop.

2010;137(4 suppl):S50.e1-9.

16. Aboudara C, Nielsen I, Huang JC, Maki K, Miller AJ, Hatcher D. Comparison of airway space with conventional lateral headfilms and 3-dimensional reconstruction from cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2009;135(4):468-479.

17. Pracharktam N, Nelson S, Hans MG, Broadbent BH, Redline S, Rosenberg C, Strohl KP. Cephalometric assessment in obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 1996;109(4):410-419.

18. Shen HL, Wen YW, Chen NH, Liao YF. Craniofacial morphologic predictors of oral appliance outcomes in patients with obstructive sleep apnea. J Am Dent Assoc. 2012;143(11):1209-1217.

19. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):136–143.

20. Klasser GD, Greene CS. The Changing field of temporomandibular disorders: what dentists need to know. J Can Dent Assoc.

2009;75(1):49-53.

21. Cote EF. Obstructive sleep apnea-- an orthodontic concern. Angle Orthod. 1988;58(4):293-307.

22. Padmanabhan S, Chitharanjan AB, Ramkumar S, Nandakumar N, Ravindran C. Surgical-orthodontic management of severe sleep apnea. J Clin Orthod. 2011;45(9):507-512, 516.

23. Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review.

Sleep. 2006;29(2):244-262.

24. Almeida FR, Lowe AA, Otsuka R, Fastlicht S, Farbood M, Tsuiki S. Long-term sequellae of oral appliance therapy in obstructive sleep apnea patients: Part 2. Study-model analysis. Am J Orthod Dentofacial Orthop. 2006 Feb;129(2):205-213.

25. Veasey SC, Guilleminault C, Strohl KP, Sanders MH, Ballard RD, Magalang UJ. Medical therapy for obstructive sleep apnea: a review by the medical therapy for obstructive sleep apnea task force of the standards of practice committee of the american academy of sleep medicine. Sleep. 2006;29(8):1036-1044.

26. Kapuniai LE, Andrew DJ, Crowell DH, Pearce JW. Identifying sleep apnea from self-reports. Sleep. 1988;11(5):430-436.

27. Katyal V, Pamula Y, Martin AJ, Daynes CN, Kennedy JD, Sampson WJ. Craniofacial and upper airway morphology in pediatric sleep-disordered breathing: Systematic review and meta-analysis. Am J Orthod Dentofacial Orthop. 2013;143(1):20-30.

28. Huynh NT, Morton PD, Rompré PH, Papadakis A, Remise C. Associations between sleep-disordered breathing symptoms and facial and dental morphometry, assessed with screening examinations. Am J Orthod Dentofacial Orthop. 2011;140(6):762-770.

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Dr. Michael S. Stosich

BioDigital Orthodontics part 13

Drs. Rohit C.L. Sachdeva Takao Kubota and John Lohse

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

A dual-arch protocol with accelerated movement and less discomfort

Drs. George Schudy and Larry White

PRODUCT PROFILE

Ortho Classic’s H4™ System has a growing suite of orthodontic solutions

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s the H4™ self-ligating bracket system has continued to grow in popularity, so has the opportunity for additional innovations and solutions. In addition to the continual improvements of the H4 bracket, Ortho Classic has released a couple of new products — the sleek new H4 prescription buccal tube and a fully esthetic H4 bracket that is ideal for today’s active, image-conscious patient, appropriately named H4 GO™.

The H4 bracket, H4 buccal tube, and H4 GO have all been designed to be efficient and predicable for the clinician, as well as comfortable and hygienic for the patient.

H4 bracket

A rigid body and tight tolerances make the difference The H4 brackets all have a low profile, rigid one-piece pad/body with zero flex or pad-to-body separations. This, along with a plus/minus slot tolerance of .001, translates into a bracket that realizes the appliance’s true prescription and reduces the amount of “finishing” work.

Ensuring full control, torque is built into the base of each H4 and H4 GO bracket and anatomically contoured (mesial-distal/ occlusal-gingival) for accurate tooth placement. The brackets have been engineered with precise angulation, placing the long axis of the root distal to the occlusal portion of the crown and all roots to align parallel.

The anatomically contoured design permits precise bracket placement with all slots aligning at the end of treatment.

Calibrated to provide optimum results The overall design of the H4 brackets has been calibrated to provide optimum results.

Precise slot depths add improved 3- to 4-point rotational and torque control, while

H4 GO bracket H4 buccal tube

H4 GO and H4 brackets

the patent-pending H4 and H4 GO bracket door, slides and locks into both open and closed positions. Minimal mesial-distal width on the door and slot adds an increased interbracket span to fully express the wire.

Large under tie-wing area supports early elastics The need to support early elastics has also been taken into consideration for the H4 bracket system. It has been designed to have an excellent tie-wing area that can support early elastics, ligatures, metal ligatures, and power chains. The smooth, rounded contours and tight tolerances of the brackets and tubes are clinically proven to be more hygienic and comfortable for the patient.

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Stronger bond strength The H4 and H4 GO patent-pending, Treadlok™ pad is a completely new and exciting improvement of pad retention technology. Not unlike the tread of a quality car tire, the Treadlok’s open flowing channel design allows air bubbles to escape, promoting maximum bond strength and multi-directional sheering protection. The combination of the Treadlok base with our H4 bonding protocol results in a stronger bond, minimizing bond failures.

To learn more about the H4 product line, visit www.orthoclassic.com or call 866-752-0065. OP This information was provided by Ortho Classic.

Volume 6 Number 1

H 4 ™ B u cc al Tu be

H4 ™ S e l f - L ig ating Br acke t H4

™

A e s t h e t ic S e l f - L ig at in g B r a c ke t

I n n o v ating Inno v at ion

Introducing the Complete H4 ™ Self-Ligating Suite Toll Free: 1.866.752.0065 | www.orthoclassic.com | Fax: 1.866.752.0066 | International: 1.503.472.8320

PRACTICE DEVELOPMENT

Does your practice have an open door for curious patients?

Advice on spreading the word on your practice’s treatment options

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recent study conducted by 3M Unitek found that both teens and adults look to the Internet more than any other medium to research braces. This fact in itself probably isn’t surprising, but what may come as news to the orthodontic community is that only 16% of survey respondents said they consulted an orthodontist for more information on braces. Combining these findings, it is clear that by the time patients come to your office, they may have already formed some very strong opinions about the available treatments — without ever having talked to you about them.

There are positive and negative aspects to this situation, but many practitioners would agree that patients are better off talking to an orthodontist before spending too much time on the Internet. If prospective patients wander too far into message boards and articles that aren’t necessarily always correct, they may talk themselves into or out of treatment methods without having a sound understanding of the fundamentals. How should orthodontists counteract this situation and get back in front of patients as the go-to source for expertise? Consider these methods: • Know the information that is out there. Study respondents reported visiting WebMD.com and www.mylifemysmile. org (the AAO’s patient-focused website) in their search for information. These sites present a general overview of orthodontic treatment, but it’s important to familiarize yourself with the content on these sites, so you can fill in the gaps with prospective patients. Study respondents also reported visiting PaintYourSmile.com and HiddenBraces.com. These sites present more targeted information on esthetic and lingual braces. Read over the information on each site, and prepare any talking points you’d like to complement the information in light of your own expertise. With this preparation, the next time a patient says, “I was reading online…” you’ll likely have a clear idea of exactly what he/she is talking about.

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• Never underestimate the power of word of mouth. Past patients or parents of past patients are often an invaluable resource for recommendations and referrals. In fact, 30% of survey respondents reported that they talked to their friends who have braces (or had them in the past) for more information. Are you maximizing the potential of your patient pool? Look for new ways to encourage patients to refer their curious friends to you, and make sure your patients get the same message that you give to referring dentists: Your office is happy to answer questions during the research process.

If you don’t already, you might consider rewarding patients or offering some form of thank you for their referrals.

• Beef up your own online presence. As they say, “If you can’t beat ’em, join ’em.”

Make sure your current website does a thorough job of communicating your message to prospective patients. Does it clearly answer the top questions you get from new patients, and is this information easy to find? Does it do an effective job of representing the culture of your practice? You might even consider starting a blog for your practice, which will not only help you create content in bite-sized pieces, but it will also improve your search engine optimization that helps prospective patients easily find out about your practice. Already have a website, but you’re

still stuck on what to put on it? Some manufacturers have specific websites, such as 3Mmarketingsource.com, to help orthodontists speak to their audience.

Manufacturer websites can provide great resources and content to help reach your existing and potential patients.

• Promote esthetics first. Challenge patients’ initial thought processes about getting braces, and make it a priority to promote esthetic treatment options such as ceramic and lingual braces online and in your practice. The study showed that when presented with information on ceramic braces, 94% of teens and 90% of adults considering braces were interested in ceramic braces. Of those respondents, 60% agreed that it’s worth paying more for an esthetic option. Presenting esthetic options first may make new patients more likely to opt for this type of treatment. Patients with beautiful, esthetic braces can also lead to positive word-of-mouth buzz and more patient referrals.

Orthodontists are the experts on braces, so it’s vital that patients know they can approach you with their questions — whether or not they’re ready to commit to treatment.

With these tips, you can position your practice as an approachable and friendly resource for prospective patients. OP This information was provided by 3M Unitek.

Volume 6 Number 1

PRACTICE DEVELOPMENT

The four imperatives of review syndication Diana Friedman discusses the value of online reviews to the dental practice

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he Internet is where personal and professional communication and interaction take place in the digital age. Phone calls have, in large part, been replaced by an ever-expanding array of online systems including email, text messaging, social media outlets (like Facebook and LinkedIn), and conferencing systems (like GoToMeeting and Skype). Considering the fact that 99% of consumers with a household income of $75K or above use the Internet,1 the Internet is the best and most economical way for a practice to gain visibility and effectively communicate with its patients.

However, using the Internet to promote your practice and engage your patient community does have its challenges. The impact of consumers’ access to digital Diana P. Friedman, MA, MBA, is president and chief executive officer of Sesame Communications. She has a 20-year success track record in leading dental innovation and marketing.

Throughout her career, Friedman served as a recognized practice management consultant, author, and speaker. She holds an MA in sociology and an MBA from Arizona State University.

Volume 6 Number 1

dental care information and the proliferation of dental practice websites make standing out from your competition and maintaining a powerful online brand quite difficult.

The good news is consumers are just as overwhelmed by the volume of information out there and have had to turn to new online tools to assist them in quickly finding the information and personal insights they need to make informed decisions. As access to information has expanded, online reviews have become impactful in helping consumers make choices about services and providers.

Not surprisingly, 90% of people surveyed stated they are influenced by online reviews.2 More significantly, an astounding 72% of consumers state they trust online reviews as much as a personal recommendations.3 The question then becomes — does this impact dentistry? And if so, in what way?

A national market research study decisively answered this question, as 70% of surveyed dental patients stated that online reviews are as important as the dentist’s credentials.4 Considering the fact that reviews are so critical to converting referrals and growing

your patient base, this article addresses four imperatives you need to put in place to optimize your online review syndication strategy to drive the most value for your practice.

1. Volume When consumers go online to make a purchase decision, they often rely on reviews from other purchasers to determine the quality of the product or service under consideration. If a practice has only a few online reviews, the credibility of those reviews is called into question — there’s just not enough input to instill the confidence needed for prospective patients to make an informed decision. The key to an effective review strategy is to have a significant number of recent reviews that confirm and reinforce the consumer’s choice of your practice.

A recent study of 98 dental practices using the Dental Sesame™ patient engagement system5 found these practices generated an average of more than 21 qualified post-appointment patient reviews each month. This volume is significant and, when syndicated online, can quickly Orthodontic practice 53

PRACTICE DEVELOPMENT build a large volume of credible and qualified reviews that prospective patients can reference when evaluating your practice.

2. Quality Volume of reviews is important as it adds credibility to your overall ranking and provides prospective patients with the confidence to choose your practice. The challenge with online reviews is that they are not all created equal. As I travel across the country and speak to hundreds of dentists, I always get anecdotal stories about negative reviews online, which the practice cannot identify or take proactive actions to correct.

The best way to combat this is to syndicate reviews you know are from your patient community and to have it happen automatically. Requiring the dental team to ask for reviews can be effective, but it requires the patient to leave the practice, remember the request, get online, and write a review. Often this means the majority of the “ask” will not yield reviews. The most efficient and effective way to overcome this challenge is to activate automated post-appointment surveys. In this process, every patient can receive an email after his/her appointment that provides a link to a simple survey. All the patient needs to do is click the link and answer the questions. A robust patient engagement system will aggregate the reviews, share them with the practice, and syndicate them immediately online.

3. Location … location ... location Having the right volume of quality reviews is the cornerstone of an effective online reputation strategy for your practice.

The next element necessary to drive patient acquisition is to syndicate these reviews to the right online portal. Traditionally, dental online review syndication systems published reviews to “microsites,” which would then (hopefully) appear within search engine results. The challenge with publishing your valuable online reviews to a microsite is that consumers rarely go there to evaluate a service provider. Equally challenging (and frustrating) is the fact that the vendors posting your reviews to their microsites will delete your online reviews if you deactivate your service — a high risk proposition for your practice.

Syndicating your reviews to a credible online destination puts the power of the reviews in front of consumers who are choosing their next dental care provider.

Sites such as Healthgrades, with annual traffic of more than 20 million visitors 54 Orthodontic practice

... the Internet is the best and most economical way for a practice to gain visibility and effectively communicate with its patients. seeking to identify a dental care provider, offer maximum exposure for your practice and ensure your online reviews remain intact should you choose to use another patient engagement vendor. Market research from Healthgrades found that an amazing 54% of visitors scheduled an appointment with a practice within a week of visiting the site and reviewing profiles in their area.

Sesame Communications recently concluded a national market research study6 and found that 94.3% of dentists with Healthgrades stated that it is important to the success of their practice. On average, practices activating a Healthgrades Enhance Profile received 11 appointment inquiries per month.

4. Focus on ROI Executing the right strategy vis-à-vis reviews is excellent. But how do you know it is working to drive new patients into your practice? It is important to use a syndication provider that can track all incoming emails and calls from the syndication site so that you are assured the strategy is working and providing value for your practice.

Final thoughts Reviews are an excellent way to build credibility with prospective patients and

encourage them to select your practice. It is important to work with a vendor that can generate the right volume of qualified patient reviews, syndicate them where it matters, and provide you with ROI data documenting new patients being driven through those channels to the practice. OP

REFERENCES 1. Pew Research. Demographics of Internet Users: Three Technology Revolutions. Pew Internet American Life Project Web site. http://www.pewinternet.org/three-technologyrevolutions/. Published August 1, 2012.

2. Gesenhues A. Survey: 90% of Consumers Say Buying Decisions are Influenced by Online Reviews. Marketing Land Web site. http://marketingland.com/survey-customers-morefrustrated-by-how-long-it-takes-to-resolve-a-customerservice-issue-than-the-resolution-38756. Published April 9, 2013.

3. Anderson M. Study: 72% of Consumers Trust Online Reviews As Much As Personal Recommendations. Search Engine Land Web site. http://searchengineland.com/ study-72-of-consumers-trust-online-reviews-as-muchas-personal-recommendations-114152. Published March 12, 2012.

4. Bassig M. What Do Dental Patients Want? Among Other Things, Online Reviews from Other Patients. Review Trackers Web site. http://www.reviewtrackers.com/dentalpatients-want-things-online-reviews-patients. Published May 6, 2013.

5. Sesame Communications. Healthgrades Enhanced Profiles: Patient Acquisition Performance Metrics [internal survey].

February 2014.

6. Sesame Communications. Digital Marketing in Dental Practices – National Study Findings. Sesame Communications Web site. http://www.sesamecommunications.com/ research/digital-marketing-in-dental-practices-nationalstudy-findings/. Published May 2014.

Volume 6 Number 1

ONE INTEGRATED SOLUTION ONE TRUSTED PARTNER

Patient Engagement Web Design

SEO

Healthgrades Social

Contact Sesame Today!

872.225.0153 sesamecommunications.com

INDUSTRY NEWS Forum 2015 workshops announced by Ormco™

Gendex announces new website launch

Ormco™ Corporation, a leading manufacturer and provider of advanced orthodontic technology and services, has announced over 30 lectures and hands-on workshops that will be offered to attendees at the annual Forum 2015 in Orlando, Florida, February 18-21, 2015.

As the largest privately sponsored orthodontic event in the world, Forum 2015 provides attendees with exclusive access to hear from respected orthodontists about the pivotal moments that shaped their thriving practices. Ormco has assembled the foremost consultants in the orthodontic industry to share insights about the challenges and successes they’ve encountered from both a practice and case management perspective. The workshops will cover clinical techniques and tips and proven marketing and financial management strategies.

Professional golfer and Hall of Famer Tom Watson will step into the spotlight as guest speaker. Watson will share an up close and personal look at his career and how he’s persevered through tough challenges along the way.

Existing and prospective attendees can access the full list of workshop topics, descriptions, and presenter bios by visiting http://forum.ormco.com/workshops.php. Attendees are encouraged to register early as workshops fill up quickly.

Gendex, a leader in dental imaging, stands by its promise to be “Always by Your Side” with its newly designed website, Gendex.com. The new website allows clinicians to simplify their imaging search on any device whether on a phone, tablet, or laptop. Highlights of the new Gendex.com offer many improved and modern, user-friendly features. The content is uniform and offers a wide range of imaging solutions, all in one place. When browsing the new site, the user will experience a cleaner and more manageable website designed with the busy practitioner in mind. One of the most significant enhancements is the new look, which allows viewers to navigate on any Internet-ready device. Information has been reorganized, making it possible to view the site on smaller screens without losing important content.

The brand new Gendex website connects the practitioner to the entire product family, including digital intraoral sensors, panoramic X-ray, Cone Beam 3D, PSP, imaging software, and more. Take a 360-degree product tour, or check out the enhanced support section — all at your fingertips, faster and easier.

Gendex is dedicated to improving dental practices and advancing patient care through comprehensive solutions and exceptional support. The new Gendex.com is a testament to that commitment.

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT The Soft Telescopic Sleep Herbst® The Soft Telescopic Sleep Herbst®* from Great Lakes Orthodontics, Ltd., offers superior patient comfort and retention, and allows some lateral and vertical movement without disengaging the appliance. Fabricated using low-profile, reinforced EVA material, this appliance is proven effective for chronic snoring and mild to moderate obstructive sleep apnea. A threaded telescopic mechanism provides controlled 1/8 mm to 1/4 mm incremental advancements up to 5 mm with a 1-mm retrusion. The Soft Telescopic Sleep Herbst® is available in white (standard), green, red, blue, and black. All Herbst® Sleep appliances fabricated by Great Lakes are approved for Medicare reimbursement.

For more information, contact Great Lakes products customer service at 800-828-7626 and ask to speak with a sleep specialist, or visit www.greatlakesortho.com. *Herbst is a registered trademark of Dentaurum, Inc.

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OrthoAccel® partners with Focus Ortho, Integrating AcceleDent FastTrac Usage Report into innovative software OrthoAccel® Technologies, Inc., announces a new partnership with Focus Ortho, a cloud-based practice management system that enables AcceleDent® providers to upload patients’ FastTrac Usage Reports. AcceleDent is a noninvasive, FDAcleared, prescription-only Class II medical device that speeds orthodontic treatment by as much as 50%. AcceleDent patients simply use the device for 20 minutes a day while the gentle pulsatile force of the hands-free unit accelerates tooth movement.

Since patient compliance is necessary to accelerate treatment, each AcceleDent unit records usage and has a USB connection that enables orthodontists to access the device’s FastTrac Usage Report. Focus Ortho software allows orthodontists to upload and store the report from the patient’s device into the practice management system during a patient’s appointment to monitor compliance and predict treatment completion. The new system was piloted by Apple Orthodontix, a 15-location orthodontic practice in the Dallas/Ft. Worth area. While Apple Orthodontix was the first practice to benefit from the software update, it is now available to all Focus Ortho customers running version 2.2 of the software.

More information can be found at AcceleDent.com or requested via email at info@orthoaccel.com.

Volume 6 Number 1

CLASS II CORRECTION SIMPLIFIED Introducing PowerScope – an innovative appliance delivering easy Class II correction like you’ve never seen before.

• Quick wire-to-wire installation • Fixed one-piece design requires no lab setup or patient compliance • Internal NiTi spring delivers 260 grams of force for continuous activation during treatment • Patient-friendly design maximizes comfort

To learn more, talk to your American Orthodontics sales representative or visit americanortho.com/PowerScope

©2015 AMERICAN ORTHODONTICS CORPORATION | +1 920 457 5051 | AMERICANORTHO.COM

LET’S REDEFINE ORTHODONTICS

The new CS 3500 makes precise digital modeling easy.

Forget about powders and trolleys. The new CS 3500 offers more attractive features, like a direct USB connection. High-res, true-color 2D and 3D capability, plus accurate 3D models with CS Model software. And avoid per-click transmission fees – just send images directly to the lab for appliance fabrication.

Streamlined workflow is now in the palm of your hand.

Call 800.944.6365 or visit www.carestreamdental.com/SUPER

© Carestream Health, Inc. 2014. 11784 OR CS 3500 AD 1214